
Class _^_Ol^£/ 
Book/ 



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Copyright }J^_ 



IQf 



COPYRIGHT DEPOSIT. 



DISEASES of CHILDREN 



FOR 



NURSES 



INCLUDING 

INFANT FEEDING, THERAPEUTIC 
MEASURES EMPLOYED IN CHILDHOOD, 
TREATMENT FOR EMERGENCIES, PRO- 
PHYLAXIS, HYGIENE, AND NURSING 



BY 

ROBERT S. McCOMBS. M.D. 

Physician to the Dispensary and Instructor of Nurses at the Children's Hospital 

of Philadelphia; Associate in Medicine at the Philadelphia Polyclinic 

and College for Graduates in Medicine 



THIRD EDITION, THOROUGHLY REVISED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS 'COMPANY 

1916 






Copyright, 1907, by W. B. Saunders Company. Revised, reprinted, and 
recopyrighted January, 1911. Reprinted September, 1912, May, 
1914, August, 1915, and January, 1916. Revised, reprinted, 
and recopyrighted May, 1916 



Copyright, 1916, by W. B. Saunders Company 




PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



JUN 10 1916 
©CI.A433338 



DEDICATED TO 

THE MEMORY OF MY WIFE 

WHOSE INSPIRATION MADE THIS BOOK A SUCCESS 



PREFACE TO THE THIRD EDITION 



In the preparation of this edition the author has 
attempted to keep thoroughly abreast of the recent 
advancement in pediatrics without unduly enlarging 
the book. 

Additions have been made to almost all of the chap- 
ters, and the author feels that everything has been 
included which has proved to be important. 

Several articles have been rewritten. New photo- 
graphs have been added. Such important subjects as 
pylorospasm, food intoxications, blood-pressure, sporadic 
typhus, typhoid vaccination, the present treatment of 
pneumonia, syphilis, and tuberculosis, and the caloric 
methods of infant feeding have been incorporated. 

The chapters on nursing have been added to and 
standardized. The author is indebted to Miss Jennie 
A. Manly and Miss A. K. Sutton for helpful suggestions 
upon points in nursing; also to the Henry Phipps Insti- 
tute of Philadelphia for privilege of making photographs 
for article on Tuberculosis. 

He wishes to thank the publishers for their many acts 
of kindness, the Children's Hospital for the new photo- 
graphs, and the many friends the book has made for 
their favorable reviews and their timely advice. 

He hopes the third edition will receive the approval 
granted the previous ones. 

Robert S. McCombs. 

211 1 Chestnut Street, 

Philadelphia, Pa. 

May, 1916. 

S 



PREFACE 



The need for a book on children's diseases for nurses 
was called to the author's attention while giving a course 
of lectures to the nurses at The Children's Hospital of 
Philadelphia. 

It was his original intention to have only the notes of 
the lectures printed, so that some form of condensed 
material might be at hand for purposes of study. This 
volume has grown from the original notes. Incorporated 
in it are the methods employed at the Children's Hospital. 
A short description of each disease found in infancy and 
childhood has been given. It is hoped that the descrip- 
tions are clear enough to enable a nurse to know what 
symptoms to expect and what complications to guard 
against. The author believes that enough anatomy and 
pathology have been included to give a clear understanding 
of the structure of the body and the changes which take 
place during disease. Treatment has been included where 
a thorough knowledge of its underlying reason is neces- 
sary for intelligent application. Treatment for emer- 
gencies will be found under the different diseases and in 
the chapter on Therapeutics. Prophylaxis, infant feeding, 
and the methods of nursing employed in childhood are 
dwelt upon. 

7 



8 PREFACE 

The author is most deeply indebted to Miss Jennie 
A. Manly for practically all the points on nursing, 
together with the receipts for infant feeding used in 
this book. 

The original photographs for this volume were taken 
at the Children's Hospital. 

In compiling the notes, the author has had frequent 
recourse to most of the text-books on children's diseases. 
For many definitions throughout the book, and the descrip- 
tion of the diseases of the kidney, he has consulted Stevens' 
Manual of Medicine. In the chapters on Gastro-intestinal 
Diseases and Infant Feeding, Holt's Infancy and Childhood 
.was often consulted. 

Robert S. McCombs. 



CONTENTS 



CHAPTER I 

PAGE 

Peculiarities of Children's Diseases ii 



CHAPTER II 
Nursing in Childhood . . 36 

CHAPTER III 
Diseases of the Respiratory Tract c . 54 

CHAPTER IV 
Diseases of the Respiratory Tract (continued) 91 

CHAPTER V 
Diseases of the Digestive Tract 112 

CHAPTER VI 

Diseases of the Digestive Tract (continued) ..o .... 129 

CHAPTER VII 
Diseases of the Digestive Tract (continued) . 140 

CHAPTER VIII 
Diseases of the Circulatory System . . o 169 

CHAPTER IX 
Nervous Diseases . 197 

CHAPTER X 

Diseases of the Urinary Tract 231 

9 



lO CONTENTS 

CHAPTER XI 

PAGE 

Diseases of the Eye, Ear, Skin, and Glandular System . . 249 

CHAPTER XII 
The Infectious Fevers = . . 264 

CHAPTER XIII 
Typhoid Fever 282 

CHAPTER XIV 
Tuberculosis 296 

CHAPTER XV 
Contagious Diseases o . • • . . . 314 

CHAPTER XVI 
Constitutional and Nutritional Diseases ■ . . 347 

CHAPTER XVII 
Infant Feeding . , 35^ 

CHAPTER XVIII 
Artificial Feeding . 376 

CHAPTER XIX 
Therapeutics 410 

CHAPTER XX 
Weights and Measures ; Abbreviations 474 

CHAPTER XXI 
Medical Terminology 4^4 

Index 495 



Diseases of Children for Nurses 



CHAPTER I 
PECULIARITIES OF CHILDREN'S DISEASES 

A child's life is divided into definite periods, namely, 
the "newborn," "infancy," "childhood," and "youth." 

Tfie Neuhorn. — It is customary to designate a babe as 
"newborn" until all traces of its prenatal or intra-uterine 
existence have disappeared. This is usually accom- 
plished by the end of the first month. 

Infancy follows the newborn period and continues until 
the eruption of the first or milk teeth is completed; it is, 
therefore, limited to the first three years of life. 

Childhood extends from the third to the seventh year, 
at which time the permanent teeth make their appearance. 

Youth includes the years from seven to puberty. 

Weight. — ^The normal infant should weigh about seven 
and a half pounds at birth. During the first week there 
is a sHght loss, but from that time on the increase should 
be steady. 

The curve during the first year is represented in the 
chart and shows approximately the proper weight for the 
different ages of the infant. 

II 



INFANT'S WEIGHT CHART. 



DnsnB n J. P. CKOZER CRIFnTH. H. D., 



Name,. 



Date of Birth,... 



Months, j « 3 4 6 1 
Weeks. I J 1* ' ' n u 15 n 19 2i| 23 k 


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PECULIARITIES OF CHILDREN'S DISEASES 1 3 



NAME, 


Weiglif Chart 

- ADM., _ AGE, 


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Fig. 2. — The above chart was designed by Miss Rena C. Fox. Head Nurse, Children's 
Department of Philadelphia Hospital. It is very useful in cases where it is desirable 
to keep account of a child's weight over a short period of time. In the larger charts a 
month's time would appear as a very small line. The heavy lines may represent any 
pound desired ; the figures being given according to first weight of child during period it 
is to be used. Each subdivision equals two oimces. 



H 



DISEASES OF CHILDREN FOR NURSES 



Birth 

6 months i5-05 

12 " 20.05 

18 " 23.00 

2 years 26.00 



Average Weight. 

Girls. Boys. 

7.16 pounds 7.55 pounds. 

16.00 



3 
4 
5 
6 

7 
8 

9 

10 
II 
12 

13 
14 
15 



31.00 
35-00 
39.08 
43.08 
48.00 
52.09 

57.05 
64.01 
70.03 
81.04 
91.02 
T00.03 
108.04. 



21.00 
24.00 
27.00 
32.00 
36.00 
41.02 
45.01 

49-05 
54-05 
60.00 
66.06 
72.04 
79-o8 
88.03 

99-03 
110.08 



Between the ages of twelve and fourteen years girls 
gain weight faster than boys. 

Height. — The average height is about twenty and a 
half inches at birth. The growth during the first year is 
about eight inches. 

The growth of the extremities is much more rapid than 
that of the trunk. The head measures in circumference 
about thirteen and a half inches. The posterior fontanels 
should close at the end of the second month and the 
anterior about the eighteenth month. 

The special senses of sight, hearing, smell, and touch 
are developed at birth. 

A normal infant is able to hold up its head during the 
second month and sit up about the sixth month. It begins 
to recognize objects during the fifth month. From the 
eighth to the sixteenth month it should learn to walk. 
The age at which an infant begins to talk varies greatly. 
In the majority of cases by the end of the first year it is 
able to form certain words, and from this time on the 



PECULIARITIES OF CHILDREN'S DISEASES IS 

development of the function of speech is rapid. At times 
perfectly healthy children have made little progress in 
their ability to talk by the end of the second year. 
Teeth. — Average table of eruption of the milk teeth: 

Centrals . 5 to 8 months. 

Laterals 7 to 10 " 

First molar 14 to 20 " 

Cuspid 14 to 25 " 

Second molar 24 to 36 " 

At three years all of the milk teeth should be in place. 
The lower teeth usually erupt first. 
The milk teeth demand the same attention as the per- 
manent teeth. 
Average table of eruption of the permanent teeth: 

First molar 5 to 7 years. 

Centrals 6 to 8 

Laterals 7 to 8 

First bicuspid 9 to 10 

Second bicuspid 10 to 12 

Cuspid 12 to 13 

Second molar. 12 to 14 

Third molar. 16 to 35, to 40 years. 

In strumous or rickety children the eruption is fre- 
quently delayed and the teeth are often brittle and fur- 
rowed. The enamel may be of poor quahty, so that they 
easily decay. 

Hutchinson^ s teeth are seen in hereditary syphilis. The 
second or permanent upper central incisors have a single 
shallow crescentic notch in the center of the edge. In 



1 6 DISEASES OF CHILDREN FOR NURSES 



5-8 MON. 



7-10 MON. 




Fig. 3. — Normal dentition (Friihwald and Westcott). 



•g^m^m. 







^^ 






Fig. 4. — Hutchinson's teeth in hereditary syphDis: a, The two upper central in- 
cisors (second dentition) exhibit deep transverse and longitudinal furrows and a concave 
notch in the edge. Although the teeth are normal in length, the width is less than normal, 
thus producing a broad interspace between the central incisors; h, the upper central 
incisors (second dentition), immediately after eruption, and the four lower incisors. The 
lower surface of the upper incisors is rough from the presence of projecting points of 
dentine. The upper teeth are short and diverge, leaving a broad interval between them. 
The four lower incisors present a number of small excrescences like nails from imperfect 
enamel formation. The base of the excrescences is everywhere in the same plane (after 
Hutchinson). 



PECULIARITIES OF CHILDREN'S DISEASES 1/ 

addition the teeth are small and pegged. They are some- 
times called "screw-driver" teeth. 

Laminated and pitted teeth are seen at times after the 
acute infectious diseases of childhood, such as measles, 






Fig. 5. — Rachitic teeth. Boy nine and a half years old. The teeth are poorly 
developed, considerably eroded and grooved. Their position is very irregular; the lower 
incisors occupy a frontal position (not in the arch of the Jaw) and the inferior maxilla 
makes an angular turn at the canine teeth (Hecker, Trumpp, and Abt). 

scarlet fever, and diphtheria. When these diseases occur 
at an early age the formation of the enamel may be affected. 
This causes such defects as irregular pits upon the crowns 
of the teeth, particularly the incisors. The pitting is 
so marked in some cases that it gives a general honey- 
combed appearance to the crowns. To ascertain if 
irregularities are due to the eruptive fevers it is necessary 
to know the age of the child at the period of the disease. 
Pits upon the incisors caused by the eruptive fevers between 



1 8 DISEASES OF CHILDREN FOR NURSES 

the ages of four and five occupy about the central area of 
the crown face. The enamel about the cutting edge of the 
teeth has already formed at this age, so that alterations 
of nutrition would not affect it. The crowns of all the 
teeth in process of formation at this age are affected in a 
similar manner. 

Diseases Peculiar to Children. — Children need differ- 
ent environments, different management, different medical 
and surgical care, and different nursing from that required 
for adults. One-third of a physician's patients are 
children. 

Diseases of infancy and of early childhood differ in 
many respects from those of adult life, but after the seventh 
year children resemble adults in their ailments more than 
they do infants. 

The following diseases are seen chiefly in infancy and 
childhood: congenital anomalies of the heart, such as 
"blue babies," due to a patulous foramen ovale; congenital 
atelectasis or failure of a part of a lung to expand; oph- 
thalmia neonatorum or a gonorrheal conjunctivitis in the 
newborn; traumatic hemorrhages and birth paralysis due 
to injuries during birth; umbilical hernia; noma or gan- 
grenous stomatitis; cholera infantum; laryngismus stridu- 
lus; enuresis; chorea; tubercular meningitis; hydro- 
cephalus; infantile cerebral and spinal paralysis; cox- 
algia; scarlet fever; measles; rubella; varicella; pertussis; 
mumps, and diphtheria. 

Etiology. — ^Heredity, accidents at birth, infection 
through the umbilical cord, improper food, and bad 
hygienic surroundings are the principal causes of disease 
or of a delicate constitution in the newborn and during 
infancy. 



PECULIARITIES OF CHILDREN'S DISEASES 1 9 

Inheritance is a very strong factor in infancy. Such 
diseases as syphilis and tuberculosis can be directly trans- 
mitted from the mother to the child. Syphilis very 
frequently is congenital. While a child is rarely bom 
with tuberculosis, the undermined constitution and the 
feeble resisting power of an infant bom of tubercular 
parents make it very likely that the disease will develop 
early in life, at times so soon after birth as to be practically 
congenital. This is especially so if they breathe the same 
atmosphere as, or are nursed by, tubercular mothers. 
Children of parents suffering with rheumatism, gout, 
Bright's disease, or alcoholism are apt to have poor resist- 
ing powers and yield easily to infection. 

Improper food and bad hygiene are the greatest causa- 
tive factors of disease in infancy. To these are due not 
only such diseases as rickets, scurvy, and marasmus, but 
also the great class of gastro-intestinal disorders. 

Diseases of the Newborn. — The newborn babe faces 
a series of accidents and infections at birth which may 
end its career before it is fairly begun. 

Asphyxia may result during birth. This may be 
caused by pressure upon the brain or umbilical cord, the 
winding of the cord about the neck, early separation of 
the placenta (the after-birth), and various maternal 
causes, such as prolongation of labor, convulsions, hemor- 
rhages, and death of the mother. After birth has been 
accomplished and the . child has cried vigorously there 
usually is no danger, unless there has been some injury 
or some intra-uterine disease of the organs of respiration, 
circulation, or the brain. Premature infants may die 
soon after delivery due to the feeble development of the 
respiratory mechanism. (For Method of Resuscitation, 
see page 454.) 



20 DISEASES OF CHILDREN FOR NURSES 

Congenital atelectasis is a failure of the lungs to expand 
after birth. It is most often seen in babies that have had 
symptoms of asphyxia at birth, or who are poorly devel- 
oped. The principal symptoms are cyanosis and pros- 
tration. These attacks may come on suddenly. They 
may be mistaken for "blue babies." (See page 159.) 

It is necessary to have the babe cry vigorously several 
times a day to fully expand its lungs. It is desirable to 
stimulate crying if it does not show a tendency in this 
direction. If sudden cyanosis should occur, the same 
treatment as is used in asphyxia should be instituted. 

Icterus^ Jaundice. — About one-third of all infants de- 
velop jaundice within the first few days after birth. It 
increases in severity for one or two days and then gradu- 
ally disappears. 

In cases where it becomes persistently worse and shows 
no signs of abating, there is probably a congenital obstruc- 
tion of the bile-ducts or an inflammation of the liver 
(hepatitis), usually due to syphilis. 

The aciite pyogenic diseases of the newborn are due 
to infection through the umbilical cord; more rarely, 
through the mouth or any wound of the skin. 

After the micro-organism enters the system it may 
cause a local cellulitis or abscess; it may attack the 
various serous membranes, giving rise to meningitis, 
peritonitis, pericarditis, and joint involvements; or it 
may cause pneumonia, gastro-enteritis, and inflamma- 
tion of the bones (osteomyelitis). 

Erysipelas, tetanus, epidemic hemoglobinuria, fatty 
degeneration of the newborn, and pemphigus neonatorum 
are diseases which are due to a like method of infection. 

Ophthalmia neonatorum (see page 251) must be con- 



PECULIARITIES OF CHIIDREN'S DISEASES 21 

sidered a pyogenic infection of the newborn, the con- 
junctiva being the seat of the local infection. 

Prophylaxis. — As the infection takes place after the 
child is born, the responsibility rests with the physician 
and nurse — with the physician at the time of cutting the 
cord, and more frequently with the nurse in the process 
of dressing the cord, bathing, or cleansing the mouth or 
eyes, possibly after having cared for a septic mother or 
another child. 

Infection may take place either before or after the 
separation of the cord. 

The dressings of the cord should be dry and sterile. 
If suppuration occurs at the time the cord separates, 
a wet bichlorid dressing should be applied. 

Ligatures, instruments, and everything which comes 
in contact with the umbilical wound should be sterilized. 
Careful attention should be given to the mouth, genitals, 
and all surfaces which are liable to chafing or excoria- 
tion. A nurse in charge of a septic mother should not 
have the care of the infant. In an institution every 
septic case should be isolated. This includes all of the 
above-mentioned diseases. 

Hemorrhages. — These are frequent during the first 
days of life. They may be due to injuries at birth or 
they may be spontaneous. They are primarily due to the 
fact that the blood-vessels are extremely delicate and 
that there are great changes transpiring in the blood 
and the circulation at this period. The most fre- 
quently seen hemorrhage is that which occurs beneath 
the scalp (cephalhematoma) , which causes a swelling on 
the vertex of the head. This increases in size gradually 
for a week or ten days and then slowly disappears 



22 DISEASES OF CHILDREN FOR NURSES 

Hemorrhages may also occur in the various viscera, 
from the umbiKcus, stomach, intestines, mouth, nose, con- 
junctiva, female genitals, bladder, and subcutaneously. 

Cerebral hemorrhages are due to pressure upon the 
child's skull during delivery, which causes a rupture of an 
artery, with the formation of a clot on the surface of the 
brain. The pressure of this clot causes paralysis of the 
parts controlled by the damaged portion of the brain. 
From this source we may have the various forms of 
paralysis seen. 

Facial paralysis is due to an injury of the facial nerve. 
It is usually caused by pressure of the forceps along the 
course of the nerve, and not to a hemorrhage in the brain. 

ErVs paralysis is due to an injury about the shoulder- 
joint. The affected arm is paralyzed. (See page 214.) 

Intestinal obstruction may be due to an absence of the 
anal opening of the rectum (atresia of the anus) or to a 
strangulated hernia. 

Every child should be examined carefully immediately 
after birth to see if the rectum is patulous. If the bowels 
move, all doubt, of course, is removed. As they should 
open several times during the first twenty-four hours, 
any failure to do so should arouse suspicion and a thor- 
ough examination by the physician should be made. 

Umbilical hernia and swelling of the breast {mastitis) 
should be protected by pads. On no account should 
squeezing of the breast be permitted. 

Congenital stridor is characterized by noisy inspirations 
which have been likened to a crowing sound. It may 
last for six or eight months, when the growth of the larynx 
causes it to steadily diminish until it entirely disappears, 
usually by the end of the second year. In spite of the 



PECULIARITIES OF CHILDREN'S DISEASES 23 

apparent difficulty in breathing the child seems com- 
fortable. 

The chief danger is from some intercurrent disease 
like pneumonia. It may cause pigeon breast, which 
may persist. 

Sclerema is a rare condition characterized by hardening 
of the skin and subcutaneous tissues, together with 
symptoms of malnutrition. 

In the treatment of these cases the physician will keep 
the child in an incubator. 

Inanition j ever is described on page 29. 

The Most Frequent Diseases of Infancy and Child- 
hood. — Diseases of the gastro-intestinal tract and broncho- 
pneumonia are seen more often than any other diseases 
before the second year. The other common conditions 
met with during this period are affections of the lymph- 
glands, tubercular meningitis, pertussis, and measles. 

After the second year the following diseases are most 
frequently seen: Disorders of nutrition, such as rickets 
and scurvy; bone and joint diseases, these being usually 
tubercular and more rarely syphilitic; diseases of the 
blood; organic diseases of the heart; pneumonia, typhoid 
fever, the acute contagious diseases, such as measles, 
mumps, pertussis, varicella, scarlet fever, and diphtheria. 

COMPARISON OF CHILDREN'S DISEASES WITH ADULT 

CONDITIONS 

The respiratory tract during infancy is undeveloped. 
The air-cells in the lungs are not so far advanced in their 
structure, nor so important in the function of respiration, 
as are the bronchial tubes. This causes an ordinary 
inflammation of the bronchial tubes, or bronchitis, to be 
a much more serious condition in infancy than in the 



24 DISEASES OF CHILDREN FOR NURSES 

adult. When the smallest tubes are involved it is called 
capillary bronchitis or bronchopneumonia. 

Pneumonia is very common in infancy and childhood. 
Before two years of age it is usually of the type of a broncho- 
pneumonia. Next to gastro-intestinal disease this form 
of pneumonia causes more deaths than any other condition 
during childhood. After two years of age the pneumonia 
is usually croupous in type, and, in contradistinction to 
bronchopneumonia, is very rarely fatal. In this respect 
it differs from pneumonia in the adult, in whom the 
mortality ranges from 20 per cent, to 50 per cent. The 
frequency of empyema as a complication of pneumonia 
and the frequency of bronchopneumonia as a compHcation 
of the acute infectious fevers are peculiarities of children's 
diseases. 

Gastro-intestinal disorders in childhood are the most 
fatal of all diseases. This is in direct contrast to adult 
life. The reason lies in the dehcate digestive power of 
infants. Toxins or poisons are formed in the intestines 
from their inability to digest and assimilate properly the 
food given. This poison is absorbed and produces 
grave results. During infancy the stomach and intestines 
are more intimately associated than later in childhood. 
Hence one is rarely affected without involving the other. 
This causes an increase in the severity of the symptoms, 
with consequent deleterious results to the child. Through- 
out childhood gastro-intestinal conditions are characterized 
by the severity of the symptoms. 

The circulatory tract, except for the congenital mal- 
formations of the heart such as valvular disease and ''blue 
babies," is usually unaffected during infancy. After two 
years of age heart diseases are common. A murmur 
should always be looked for in cases of chorea, rheuma- 



PECULIARITIES OF CHILDREN'S DISEASES 2$ 

tism, and the acute contagious diseases. A peculiarity of 
childhood is the development of endocarditis following 
mild attacks of rheumatism. Aneurysms and arterio- 
sclerosis are uncommon. 

Anemia is often present in children. 

The Genito-urinary Tract. — The kidneys are rarely 
affected in childhood except as a sequel of scarlet fever. 
As this is a very common complication of scarlet fever, all 
those suffering from the disease should be kept under close 
observation. 

Enuresis is common in childhood. 

The various malformations of this tract are common in 
childhood, especially phimosis. 

Diseases of the Nervous System. — Hemorrhages 
are usually on the surface of the brain, and not within its 
substance. They usually occur at birth. Birth paralysis 
results. The portion of the cortex at which such hemor- 
rhages occur fails to develop, and the injury is permanent. 

Such conditions as chorea (St. Vitus' dance), laryngis- 
mus stridulus, nodding spasms, tetany, infantile paralysis, 
and tubercular meningitis are typically children's diseases. 

One of the peculiarities of children is to have convul- 
sions from trivial causes, without any lesion of the brain 
being present. 

Diseases of the Eyes, Ears, Skin, and Glandular 
System. — Ophthalmia in the newborn is very often seen 
in the poorer classes and causes about 30 per cent, of all 
adult blindness. Conjunctivitis is often seen, espe- 
cially associated with measles and catarrhal conditions 
of the nose and throat. Strabismus is not uncommon. 

Otitis media and mastoid disease are more frequent 
in childhood than in the adult. Running ears, following 



26 DISEASES OF CHILDREN FOR NURSES 

the contagious diseases, especially measles, is a common 
complication. Eczema is often observed in artificially fed 
children. 

Tubercular adenitis is seen more often in childhood 
than in the adult. 

The Acute Infectious Fevers. — Most of the diseases 
seen in adults attack children. Malaria is common. 
Hereditary syphilis is observed in childhood, the majority 
dying before they reach maturity. 

Typhoid jever is quite a common disease in children 
living in large cities. It differs from typhoid fever in the 
adult in that its onset is usually more sudden, manifesting 
itself as often in the appearance of fever, vomiting, and 
prostration as in the usual slow, insidious beginning. In 
the course of the disease constipation is more frequent 
than diarrhea, tympanites is not so marked, the eruption 
is less constant, the nervous symptoms are not as apt to 
be found as in adults, hemorrhage and perforation are 
also met with less often, and the mortality is lower. 

Tuberculosis is common in childhood. In infants under 
two years of age the lung is the part affected; beginning 
with the second year tubercular meningitis is more often 
found; and after the third year tuberculosis of the bones, 
the lymph-glands, peritoneum, and intestines becomes 
more frequent and are seen throughout childhood. Pott's 
disease and coxalgia are rarely seen except in childhood. 

The contagious diseases are typically children's diseases. 
While they may attack unprotected adults, they are com- 
paratively rare after fifteen years of age. 

Constitutional and Nutritional Diseases. — Rheuma- 
tism is rarely of the acute articular type in children. It 
is often exhibited only by stiffness and sHght aching pains 



PECULIARITIES OF CHILDREN'S DISEASES 



27 



in the limbs (''growing pains"). The frequency of 
endocarditis as a compHcation of rheumatism, even when 
no more severe symptoms than growing pains are present, 
makes it necessary that such cases should be put to bed 
and receive proper treatment. 

Diabetes mellitus is uncommon in childhood, but when 
it does occur the course is very rapid and fatal. 





Fig. 6. — Genu valgum. B'emale child 
five years old (Napier). 



Fig. 7. — Genu varum from rachitis 
(Napier). 



Scurvy is seen in artificially fed infants. 

Rickets and marasmus are typical nutritional diseases 
seen only in childhood. 

Orthopedics. — Many children have deformities due to 
rickets, spinal curvatures, congenital dislocation of the 
hips, and contractions of the tendons. These deformities 
are overcome by surgical treatment. 



28 DISEASES OF CHILDREN FOR NURSES 

Various terms are given to the different deformities: 
Clubbed hands ; webbed fingers ; congenital dislocation of 
the hips; knock-knees or genu valgum; bow-legs or genu 
varum; bowing of tibia; club-feet or talipes varus; and 
talipes valgus; Polydactyly or six fingers. 

Symptomatology. — In children the onset of disease is 
usually more sudden, the temperature higher, the pulse 
and respirations more accelerated, the physical signs more 
pronounced, the course shorter, and the recovery more 
rapid than in an adult. 





Fig. 8. — Talipes valgus (Kerr). Fig. 9. — Talipes varus (Kerr). 

All temperatures in children are higher than in adult life. 
Frequently a temperature of 104° F. to 105^ F. is seen in 
cases of ordinary pharyngitis and mild tonsillitis. Fever 
in children apparently results from the slightest cause. 
This is better understood if one realize that the nervous 
mechanism of a child is more sensitive than that of an 
adult. Consequently a fever in a child does not indicate 
as much as in an adult and need not cause anxiety unless 
prolonged. It is the continuous high temperature which 
indicates serious illness. On the other hand, the tempera- 
ture is easily depressed, owing to the great vascularity 
of the skin, by exposure, by sleep, and by inactivity. 



PECULIARITIES OE CHILDREN'S DISEASES 29 

Inanition fever is a term applied to a peculiar elevation 
of temperature occurring in the ne^^born. It is generally 
seen during the first five days of life, and is apparently due 
to the fact that the infant gets very little, often nothing 
at all, from the breast. The temperature may rise to 
102 ° or 104° F., and is associated with rapid loss of weight. 
As soon as milk is secreted in abundance, or when the 
child is placed upon a full breast, artificial food, or even 
water, if given freely, the temperature falls to normal. 
It is important that such a fever should be recognized, 
because it gives at times the first warning of a condition 
which may prove fatal. The temperature of every child 
should be taken during the first week. 

The normal pulse in infancy and childhood is of lower 
tension than in an adult and varies in frequency according 
to the age. The first few weeks after birth it beats from 
120 to 150 times per minute. In the second year the 
pulse falls to no; in the third or fourth year to 100; in 
the seventh to 90; and in the twelfth to 80. Slight causes 
may produce wide variations of the normal pulse due to 
the unstable nervous mechanism of a child. 

The respirations during the same period likewise vary- 
In the newborn they are from 30 to 60 per minute; in the 
first year 28 to 30; at five years 22 to 25; at fourteen years 
20; and in adult fife 18. The peculiar variations of the 
respiration seen in childhood are due to the same nervous 
origin which influences the temperature and pulse. 

The function of digestion in infancy is delicate and 
undeveloped. Infants are able to digest about 4 per cent. 
of fat, 6 per cent, of sugar, and 2 per cent, of proteid during 
the first year. 

Infants cannot tell their symptoms, so it is necessary to 



30 DISEASES OF CHILDREN FOR NURSES 

study them to find out their ailments. The principal 
means a child has of explaining its wants, discomforts, 
or pains is by crying. A child cries from pain, hunger, 
discomfort, or habit. 

The cry of hunger is usually fretful, is accompanied by 
the sucking of its fingers, and. ceases when satisfied. 

The cry of indigestion simulates the cry of hunger, but 
does not cease when the child is fed. 

The cry of pain is usually sharp and is accompanied 
by contractions of the features, drawing up of the legs, and 
signs of distress. If the child fall asleep from exhaustion 
it soon awakens, usually with a scream. It is well to 
remember that a severe pain in infancy may be due either 
to colic or earache. The child simply moans when the 
pain is less severe. 

The cry of weakness is a feeble whine. 

The cry oj temper is prolonged, violent, and is attended 
with stiffness of the body and the throwing about of the 
arms and legs. 

The cry oj habit ceases when the child is satisfied and 
may be caused by a desire for any familiar object, such as 
a doll, nipple, or rattle. 

There are also characteristic cries heard in certain 
diseases such as hydrocephalus, meningitis, marasmus, 
hereditary syphihs, and pneumonia. 

In hydrocephalus and meningitis a child will scream 
out shrilly in the night. This is called the hydrocephalic 
cry and is also sometimes heard in chronic bone diseases, 
due to pain. 

In marasmus there is the feeble whine; in hereditary 
syphilis a nasal cry; in pneumonia the cry is short, catching, 
and suppressed. 



PECULIARITIES OF CHILDREN'S DISEASES 3 1 

Feeding and Therapeutics. — The entire subject of 
feeding in infancy and childhood is one of the most im- 
portant branches of pediatrics. 

The therapeutic measures employed differ in many 
respects from adult treatment. 

Prognosis. — The younger the child, the worse the prog- 
nosis. This is because of the feeble resisting power and 
lack of development. On the other hand, many conditions 
can be outgrown, as the structures and organs increase 
in size and strength develops. 

Most deaths in the first year are due to marasmus, 
affections of the gastro-intestinal tract and to broncho- 
pneumonia. Practically the only deaths due to nervous 
origin are from meningitis and convulsions. Of the acute 
contagious diseases, usually measles and pertussis are the 
only offenders. Of the chronic diseases, tuberculosis 
stands alone. 

Sudden deaths occur from the following causes: mal- 
formations; internal hemorrhage; asphyxia from overlying; 
asphyxia from the aspiration of food into the larynx and 
trachea; asphyxia from enlarged thymus gland; atelec- 
tasis; convulsions; and marasmus. 

In the second year there are the same causes of death as 
in the first, with the exception of marasmus, which for- 
tunately does not extend into this period. 

From the second to the fifth year scarlet fever, diph- 
theria, general diseases of the lungs, and tubercular 
meningitis are the diseases causing death. 

From the fifth to the fifteenth year there is low mortaHty. 
It is chiefly made up of deaths resulting from diphtheria, 
scarlet fever, diseases of the lungs, tubercular meningitis, 



32 DISEASES OF CHILDREN FOR NURSES 

diseases of the bones, appendicitis, rheumatism, and 
cardiac conditions. 

Quarantine. — The diseases which must be isolated by 
the regulations of the Boards of Health of different cities 
vary so that no accurate rule can be given. Scarlet 
fever, small-pox, diphtheria, epidemic cerebrospinal 
meningitis, yellow fever, and cholera are universally 
isolated. 

In addition, many other diseases must be reported. 

Sections from the laws of the State of Pennsylvania are 
given as an example of what regulations must be expected 
in cases of infectious and contagious diseases. 

In addition, no one who is suffering from the diseases 
mentioned, nor anyone who has charge of the persons so 
suffering, is permitted to ride in a public conveyance, and 
the patient cannot enter a private vehicle without con- 
sent of the health authorities and without making pro- 
vision for thorough fumigation of the vehicle after use. 

Other provisions are made covering bedding, infected 
clothing, etc., and renting of rooms which have been 
occupied by persons suffering from tuberculosis or other 
infectious diseases, without fumigation. 

Section i. Be it enacted, etc., That every physician, practicing in 
any portion of this Commonwealth, who shall treat or examine any 
person suffering from or afflicted with actinomycosis, anthrax, bubonic 
plague, cerebrospinal meningitis — epidemic (cerebrospinal fever, spotted 
fever), chicken-pox, Asiatic cholera, diphtheria (diphtheritic croup, 
membranous croup, putrid sore throat), epidemic dysentery (bacillary 
or amebic dysentery), erysipelas, German measles, glanders (farcy), 
rabies (hydrophobia), leprosy, malarial fever, measles, mumps, pneu- 
monia (true), puerperal fever, relapsing fever, scarlet fever, (scarlatina, 
scarlet rash), small-pox (variola, varioloid), tetanus, trachoma, trichinia- 
sis, tuberculosis in any form, typhoid fever, paratyphoid fever, typhus 
fever, whooping-cough, yellow fever, anterior poliomyelitis, impetigo 



PECULIARITIES OF CHILDREN'S DISEASES 33 

contagiosa, pellagra, scabies, or uncinariasis shall report the case to the 
health authorities. 

Section 2. Upon receipt by the health authorities of any township 
of the first class, borough, or city, or by the health officer of the State 
Department of Health, of a report of the existence of a case of anthrax, 
bubonic plague, cerebrospinal meningitis — epidemic (cerebrospinal 
fever, spotted fever), chicken-pox, Asiatic cholera, diphtheria (diph- 
theritic croup, membranous croup, putrid sore throat), German measles, 
glanders (farcy), leprosy, malarial fever, measles, mumps, relapsing 
fever, scarlet fever (scarlatina, scarlet rash), small-pox (variola, varioloid), 
tj^phoid fever, paratyphoid fever, typhus fever, whooping-cough, or 
yellow fever, the said health authorities or the health officer of the State 
Department of Health, as the case may be, will quarantine the residence. 

Quarantine Periods — // Antitoxin Has Been Used — Cidttires. 
Section 4. The quarantine period for anthrax, bubonic plague, cere- 
brospinal meningitis — epidemic (cerebrospinal fever, spotted fever), 
Asiatic cholera, typhus fever, yellow fever, relapsing fever, leprosy, and 
whooping-cough shall be until the recovery, death, or removal of the 
patient so suffering, and shall be determined in accordance with the rules 
and regulations of the health authorities. The quarantine period for 
small-pox (variola, varioloid) and scarlet fever (scarlatina, scarlet rash) 
shall be a minimum period of thirty days, or until such time thereafter as 
the last person in the premises so suffering shall have fully recovered, or 
until death or removal. The quarantine period for diphtheria (diph- 
theritic croup, membranous croup, putrid sore throat) shall be a mini- 
mum period of twenty-one days, or until complete recovery or the death 
or removal of the patient : Provided, That if antitoxin has been used for 
curative purposes for the patient, and for the immunizing of all of the 
inmates of the premises, and two negative bacteriological cultures have 
been secured from the diseased area of each patient on the premises for 
two successive days, the minimum period of quarantine may be fourteen 
days. The quarantine period for measles, German measles, chicken-pox, 
and mumps shall be for a minimum period of sixteen days, or until the 
recovery of the last person on the premises so suffering, or until complete 
recovery or the death or removal of the patient. 

Exclusion from Places of Amusement, Public Gatherings, Places of Business, 

Churches, Schools, Etc. 
Section 7. No child or other person residing in the same premises with 
any person suffering from anthrax, bubonic plague, cerebrospinal menin- 

3 



34 DISEASES OF CHILDREN FOR NURSES 

gitis — epidemic (cerebrospinal fever, spotted fever), Asiatic cholera, 
small-pox (variola, varioloid), typhus fever, yellow fever, scarlet fever 
(scarlatina, scarlet rash), relapsing fever, leprosy, diphtheria (diphtheritic 
croup, membranous croup, putrid sore throat), measles, German measles, 
chicken-pox, or mumps, shall be permitted to attend any place of amuse- 
ment, or any church, or other public gathering, or to be exposed, except 
by permission of the health authorities, on any public street or in any 
store, shop, factory, or other place of business, or be permitted to attend 
any public, private, parochial, Sunday, or other schools; and the teachers 
of public schools, and the principals, superintendents, teachers, or other 
persons in charge of private, parochial, Sunday, ©r other similar schools, 
are hereby required to exclude any and all such persons from said schools; 
such exclusion to continue until the quarantine is lifted and the premises 
thoroughly disinfected. 

Disinfecting Bath, Etc. — Removal — Bath, Ete. — Use of Antitoxin — 
Admission to School — Removal — Immunes — Admission to School. 
Section 8. Any child or person residing on the same premises with 
any person suffering from anthrax, cerebrospinal meningitis — epidemic 
(cerebrospinal fever, spotted fever) , or typhus fever may be allowed after 
taking a disinfecting bath and putting on disinfected clothing, to remove 
from the said premises and take up his or her residence on other premises, 
and may after such removal be admitted into any of the said schools; and 
any child or person residing on the same premises with any one suffering 
from diphtheria (diphtheritic croup, membranous croup, putrid sore 
throat), may be allowed, after taking a disinfecting bath and putting on 
disinfected clothing, and after antitoxin has been administered for 
immunizing purposes, to remove from the said premises and take up 
his or her residence on other premises occupied by adults; and may, after 
five days from said removal, be admitted into any of the said schools; 
and any child or person residing on the same premises with any child 
suffering from scarlet fever (scarlatina, scarlet rash), measles, German 
measles, mumps, or chicken-pox, may be allowed, after taking a disin- 
fecting bath and putting on disinfected clothing, to remove from the said 
premises, and take up his or her residence on other premises occupied 
only by adults, or by children who are immune to the disease (scarlet 
fever, scarlatina, scarlet rash, measles, German measles, mumps, or 
chicken-pox), existing on the said premises from which the said child or 
person has removed, such immunity being shown by the official health 
records, and may, fourteen days after such removal, be admitted to any 
of the said schools: Provided, That if the child or person residing on the 



PECULIARITIES OF CHILDREN'S DISEASES 35 

same premises with any person suffering from any of the said diseases 
(scarlet fever, scarlatina, scarlet rash, measles, German measles, mumps, 
or chicken-pox), and removing therefrom as above provided, is himself 
or herself immune from the disease existing on the said premises, by virtue 
of a former attack, this fact being shown by the official health records or 
by other evidence satisfactory to the health authorities, such immune 
child or person may, on the day following such removal, be admitted to 
any of the said schools; and any child or person residing on the same 
premises with any person suffering from relapsing fever may be allowed, 
after taking a disinfecting bath and putting on disinfected clothing, to 
remove from the said premises, and take up his or her residence on other 
premises, and may, after ten days from such removal, be admitted to any 
of the said schools. 



CHAPTER II 
NURSING IN CHILDHOOD 

The problems which confront the nurse in the manage- 
ment of children are vastly different from those encoun- 
tered among adults, but the fundamental principles of 
nursing are the same. The methods of treatment are in 
many respects identical, or only sHghtly altered to adapt 
them to the young patient. The methods of amusement 
and entertainment can be appreciated by all who have 
come in contact with children, and success in handling 
them depends entirely upon the nurse's temperament. 

It is the professional side of the nurse, her value to the 
physician in attendance, which demands the special train- 
ing in children's diseases. It is necessary to know the symp- 
toms and to be able to report them intelhgently. This 
calls for careful, trained observation, as the child cannot 
describe its feelings accurately. The detail of symptoms 
cannot be recited by the patient, but has to be recognized 
and tabulated by the nurse. 

It is necessary to understand the principles of infant 
feeding and hygiene. These are the two most important 
subjects of pediatrics. Knowledge of milk mixtures and 
their preparation is essential. Accuracy is demanded 
both by the infant's digestion and by the physician. The 
delicate mechanism of an infant's stomach cannot digest 
foods unless they contain the proper proportion of fat, 
sugar, and proteid. The physician's whole plan of treat- 
36 



NURSING IN CHILDHOOD 37 

ment is rendered useless unless he knows the percentage 
of these ingredients in the mixture the child is getting. 
The proper methods of feeding in malformations and 
intubations must be understood. 

Hygiene is a vast subject in itself. In infancy the sur- 
roundings and the personal attentions are of greater 
value than at any other time of hfe. 

It is necessary to understand the significance of the 
stools in infancy. The character of these acts as a guide 
to the physician in the treatment of the case and in the 
construction of his milk mixtures. In the same way the 
character of the vomit is important. 

The methods of treatment in childhood must be thor- 
oughly comprehended. The subject of prophylaxis and 
the care of the contagious cases is the field in which the 
nurse is in supreme command. By never permitting a 
lapse in her technic nor carelessness in her methods she 
does more for the prevention of disease and the health of 
the human race than any other factor in medicine. 

GENERAL HYGIENIC MANAGEMENT OF CHILDREN 

The Newly Born. — Immediately after birth the child 
should be wrapped in a blanket and placed in a warm 
room. The eyes should be washed with boric acid or, 
in cases where there has been a pre-existing vaginal dis- 
charge one or two drops of a 2 per cent, solution of silver 
nitrate should be used (Crede's method). The child 
should then be thoroughly greased and given a warm bath 
at a temperature of 100° F. An antiseptic dressing 
should be applied to the cord and a flannel binder placed 
around the abdomen. 

It is preferable to have the child sleep in a crib. 



38 DISEASES OF CHILDREN FOR NURSES 

Care of the Cord. — The cord should be kept dry and 
disturbed as Httle as possible until it drops off; this usually 
occurs on the fifth day. After this has happened an 
antiseptic dressing and a square pad should be placed 
over the navel and held firmly in place by the binder, 
to prevent umbilical hernia. 

Bathing. — After the separation of the cord the full bath 
can be given daily. The water should be about ioo° F. 
The middle of the day and the warmest part of the room- 
are the time and place to select. The bath should take 
only a few minutes, and vigorous rubbing should be 
avoided. 

Clothing. — This should be light in texture, warm, and 
nonirritating. The chest and arms should be covered 
with a woolen undershirt, and all clothing should hang 
from the shoulders. Canton flannel or stockinet make the 
best diapers. The feet must be warm, as cold feet are 
responsible for many attacks of colic and indigestion 
(Hoh). 

The night clothing should consist of a light flannel 
gown, hung from the shoulders. Too much covering 
may cause disturbed sleep. In summer the outer clothing 
should be light and the underclothing of the thinnest 
flannel or gauze obtainable. 

Special Hygienic Measures. — ^The eyes should be 
washed with boric acid for the first few days and at any 
time upon the appearance of a discharge from the eye. 
Infants should be kept in a darkened room. The tem- 
perature should be taken daily during the 'first week 
(see page 29). 

The mouth should be cleansed with a soft rag wet with 
sterile water. A solution of bicarbonate of soda, 20 gr. 
to the ounce, should be employed if there are any signs 



NURSING IN CHILDHOOD 39 

of inflammation or thrush. In such cases the mouth 
should be cleansed with this solution after each feeding. 

The breasts in both sexes often become swollen a few 
days after birth. If they are not interfered with, this 
disappears in a short time. 

Genitals. — In boys the foreskin should be retracted 
daily and greased. The skin is very delicate in infants; 




Fig. 10. — The " Children's Hospital Bed." A properly constructed bed for infants. 

the urine frequently causes scalding and blistering of the 
surfaces, especially in fat babies. If this occurs the 
napkins must be removed as soon as soiled; the skin 
should be bathed only once a day with water (for all 
other cleansing purposes olive oil should be used) ; and 
a powder consisting of balsam of peru, 10 per cent, tal- 



40 DISEASES OE CHILDREN FOR NURSES 

cum, starch, cornmeal, or stearate of zinc, dusted upon 
the inflamed areas, in all the folds of the skin, and over 
the diaper. The best dusting powder is probably the 
balsam of peru, lo per cent., combined with stearate of zinc. 
Bran baths are advantageous at times (see page 440) . 

Airing. — In summer a newly bom babe can be taken 
out at the end of the first week; in winter, at one month. 
All children should receive all the sunshine and fresh air 
obtainable. 

Sleep. — During the first few weeks a child sleeps from 
twenty to twenty-two hours during the day. An infant 
should not be allowed to sleep at the breast or with a nipple 
of a feeding bottle in its mouth. The babe should be 
awakened every two hours for its feeding. 

Infant feeding is discussed in Chaps. XVII. and XVIII. 

Infancy. — Bathing. — By the sixth month the tempera- 
ture of the bath can be reduced to 95° F. and by the end 
of the first year to 90° F. Older children should receive 
a cold douche with water of about 70° F. after the bath, 
while standing in a tub of warm water. 

At times infants get blue after the bath, especially if 
deHcate. Under such conditions it is better to discontinue 
tub bathing and depend upon the bed baths. 

Clothing. — The abdominal band can be dispensed with 
after the first few months. In very thin infants it may be 
continued, to maintain the proper protection to the abdo- 
men. 

Low neck and short sleeves should not be allowed. 
The night clothing should be a light flannel gown hung 
from the shoulders. The night clothes should be an 
entirely different set from those worn during the day. 

Special Hygienic Measures. — The teeth should be kept 



NURSING IN CHILDHOOD 4 1 

clean to prevent caries. The child should be trained 
to have its bowel movements and urinate at selected 
times. 

Sleep. — During the first six months the child will sleep 
from sixteen to eighteen hours during the day. At one 
year it requires from fourteen to fifteen hours of sleep and 
at two years, thirteen or fourteen hours. An infant's 
position should be changed often during sleep. 

Exercise. — An infant usually obtains plenty of exercise 
from crying and throwing its arms and legs about. Walk- 
ing should be attempted during the period from the eighth 
to the sixteenth months, provided there is no tendency to 
rickets. Talking should be encouraged. 

Childhood. — Bathing. — During childhood the warm 
bath should be given at night and the cold bath or sponge 
in the morning. 

Clothing. — Woolen undergarments in winter and light 
textures in summer are the rule. The night clothing 
should consist of woolen union suits with feet, if there is 
a tendency to get from under the covers. 

General Hygienic Measures. — The bowel movements 
should be kept regular. Any illness or disorder should be 
immediately attended to. 

Sleep. — At the age of four years eleven or twelve hours 
sleep are required. 

Exercise. — The playroom should be cool — from 60° F. 
to 65° F. (Holt). The clothing should be loose, to give 
the freest possible motion of the muscles. Out-of-door 
exercises are the most healthful. 

The proper methods of feeding for children over two 
years of age is discussed in Chapter XVIII. 

Youth. — Sleep. — The amount of sleep required from 



42 DISEASES OF CHILDREN FOR NURSES 

the sixth to the tenth year is from ten to eleven hours. 
From the tenth to the fifteenth year at least nine hours 
of sleep are necessary. 

An out-door life with plenty of exercise, frequent bathing, 
and instant attention to ailments lays the foundation for 
sturdy manhood and womanhood. 

The nursery should be the sunniest and the best 
ventilated room in the house. Nothing which could 
contaminate the air of the room should be allowed. The 
temperature should be from 68° F. to 70° F.; no higher. 
The room should always be thoroughly aired at night. 
The floors should be covered with rugs, as they are cleaner 
than carpets. An infant requires about 1000 cubic feet 
of air, older children about 700 to 800 cubic feet. 

Premature Babies. — The conditions which have to be 
combated under these circumstances are the problems of 
maintaining the body heat, and feeding. 

Incubators. — These are so arranged that an even tem- 
perature may be maintained: 98° F. in very dehcate in- 
fants and from 85° F. to 95° F. in more robust babies. 
At the same time the air is moistened and ventilation is 
secured. 

In constructing an incubator the lower portion consists 
of a hot-water tank (hot-water bottles may be used), above 
which is an inlet for air. The bed should occupy a position 
midway in the air chamber and be so arranged as to allow 
the air to circulate freely around its foot. An exit for the 
air should exist above the child's head. A moistened 
sponge should be placed at the foot of the bed. 

The child is kept in the incubator until it reaches full 
term. Before removing, the temperature should be 
gradually lowered. 



NURSING IN CHILDHOOD 



43 



In feeding these children, gavage often has to be resorted 
to. At seven months of age J ounce should be given 
every hour and a half. At eight months f ounce at the 
same intervals. 

In small full-term babies it is also necessary to maintain 
the body heat. This is best accomphshed by wrapping 




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Fig. II. — Cross-section of a wooden incubatqr of simple construction, with glass 
lid (F): The air enters through the opening A, which can be regulated by means of a 
damper, passes over the bottles filled with Lot water, the saturated sponge, and the ther- 
mometer, and escapes through the ventilator K. (Friihwald and Westcott). 

them in cotton and blankets. Hot-water bottles may 
also be employed. 



ROUTINE EXAMINATIONS 

Temperature. — ^When taking the temperature of the 
child it is not always possible to teach them to hold the 
thermometer in the mouth properly, and for young children 
and infants this method is impracticable. The rectum, 
the axilla, or the groin are then utilized for this purpose. 
The thermometer should be greased with ordinary vas- 



44 



DISEASES OF CHILDREN FOR NURSES 



elin when introduced into the rectum and the temperature 
marked ''rectal" on the chart or read one degree lower 
than the mercury indicates, as the local temperature in 
that part is about one degree higher than in the mouth. 
If an infant struggles while taking a rectal temperature^ 
turn it on its face, or hold its face downward on your knee. 




Fig. 12. — Method of taking the rectal temperature of an infant or young child (Kerr). 



When the thermometer is inserted, with the child in this 
position, it should be pointed downward, toward the um- 
bilicus, as the axis of the rectum has been changed. 

When the rectum is diseased it should not be chosen for 
the place to take a temperature. 

In the axilla or groin the temperature should be marked 
"axillary" on the chart or read one degree higher, as there 



NURSING IN CHIIDHOOD 



45 



is that much difference in temperature between these 
locahties and the mouth. The skin should be thoroughly 
dry and the thermometer closely surrounded by folds of 
skin. 

Pulse. — The pulse is best obtained in the groin or at 
the temporal artery in infants. The normal rate for the 
different ages is given on page 29. 




,Jk' 



Fig. 13— The method of obtaining the temperature at groin. The skin should be 
free from moisture. The thermometer is laid in the fold of skin between thigh and 
abdomen and is held in place by crossing thighs. 

Respiration. — ^The normal rate for the different ages 
is given on page 29. 



COLLECTIONS FOR CLINICAL EXAMINATIONS 

Method of Collecting Urine. — In males it is a good plan 
to place the penis in the neck of a bottle which lies between 
the thighs and is held in position by a square of adhesive 
plaster, the center of which is pierced, making a hole large 
enough to grip the neck of the bottle. 



46 DISEASES OF CHILDREN FOR NURSES 

In females a small pan placed under the buttocks will 
answer, or a bottle can be arranged as described above. 
If these methods fail, catheterize. 

The diapers are saved in cases where the stools are to 
be examined. 

The blood is examined to determine the number of 
red and white blood-corpuscles, the percentage of hemo- 
globin, and for malarial organisms. For method, see 
page 191. 

The Wassermann reaction for syphilis and the com- 
plement fixation test for gonorrhea are also made with 
the blood. 

The sputum is examined for tubercle and other bacilli, 
and should be expectorated into a sterile, wide-mouthed 
bottle. 

In children under four years of age, the best method to 
obtain sputum is as follows: Have an applicator with 
sterile cotton about the tip. Grasp the tongue, pulling it 
as far forward as possible, and pass the applicator back to 
the pharynx, keeping as close to the tongue as possible. 
The irritation of the pharynx will excite coughing, and the 
sputum may be swabbed out. 

The applicator may be placed by the child's bedside, 
and when the nurse notices a severe attack of coughing the 
child is picked up and the sputum obtained in the same 
manner. Another very easy method of obtaining sputum 
is to insert a large (J -ounce) eye dropper into one end of a 
catheter, compress the bulb, and pass the catheter back to 
the pharynx, then allow the bulb to expand, this produces 
suction and draws the sputum into the catheter. 

Cerebrospinal fluid is examined for various organisms. 
For method, see page 210. 



NURSING IN CHILDHOOD 



47 



Diphtheria bacilli are looked for in smears taken from 
the nose and throat. It is at times desirable to have the 
nurse obtain the culture from a suspected case of diphtheria. 
To do this she must have a platinum loop and a test- 
tube containing the proper culture media (Loffler's blood- 



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Fig. 14. — Method for keeping nurse's record. 



serum). These tubes should always be kept on ice until 
needed. 

Before using the platinum loop it should be heated in 
the blue portion of an illuminating gas flame or, better, 
over a Bunsen burner until it is red hot. 



48 DISEASES OF CHILDREN FOR NURSES 

After carefully removing the cotton stopper from the 
end of the test-tube, and holding it between the fingers 
in such a way that the portion which enters the tube comes 
in contact with nothing, the suspected spot in the throat 
or nose is gently rubbed with the loop of platinum. The 
thin film which forms between the loop is then spread 
over the culture media, being careful not to allow it to 
touch anything in transferring it from the infected area 
to the media. The cotton stopper is then reapplied, and 
the platinum wire again heated as before to destroy all 
germs it may still have upon it. The culture media 
should then be placed in a thermostat as soon as possible. 
Other discharges or parasites, like pus, pleural fluid, 
intestinal worms, etc., should be preserved in sterile test- 
tubes. 

SPECIAL INSTRUCTIONS 

Never leave a child alone in a tub. 

The infant should be weighed twice a week. 

The personal care of sick children demands closer 
attention than that required in adults. Often the child 
cannot express his want at all. The study of the various 
cries, as described on page 30, will often give the nurse 
an insight into their desires. 

The fact that the urine, feces, and vomited material 
are frequently passed without any indication on the part 
of the child renders frequent examination, as to these 
conditions, necessary. Children do not expectorate until 
four years of age; before that time the sputum is swallowed. 

In institutions the hair should be carefully scrutinized 
for pediculosis capitis. 

At times water is greatly craved by children, and this 



NURSING IN CHIIDHOOD 49 

fact is often overlooked. They should have small amounts 
between feedings, except in acute gastritis or after an 
operation, when cracked ice can be substituted. 

In cases of illness infants can be held in the arms, 
excepting in cases which require absolute rest. Older 
children must be moved from side to side. Delirious 
children may require cuffs and strait-jackets (see pages 
467 and 468). 

When a child is being held for examination, do not 
press its arms down on the front of the chest. 

When any portion of the respiratory tract is involved, 
do not tuck the bed-clothing in too tightly. 

Sponging with tepid water (or a hot bath, 110° F.) will 
often quiet a restless child. Observe children's spines; 
slight deformities, if recognized early, are easily corrected. 

Children with rickets should be kept off their feet, 
and the nurse should train them to sit and lie straight. 
Children's toys should be boiled frequently, when possible, 
if there is a tendency to place them in the mouth. In- 
fants' rattles and articles upon which they are permitted 
to bite should be tied in such a way that they will not fall 
upon the floor, and should also be frequently boiled. 

Always place a clean sheet, preferably covered with a 
blanket or some similar device, under the infants if they 
are upon the floor. The nursery should be covered 
with a fabric which is easily cleaned and readily changed. 

All draughts should be avoided when children are play- 
ing on the floor. A child should not be allowed to lie 
under an open window. 

Children should be kept as quiet as possible after their 
evening meals, to avoid "night terrors." 

Do not allow a child to lie or sit gazing at the sun. 
4 



50 DISEASES OF CHILDREN FOR NURSES 

When the rectum is diseased it should not be chosen as 
a place to take temperature. 

When giving a rectal irrigation in any of the diseases 
of the lower bowel, it must be done slowly in order to avoid 
pain. 

Cold compresses to the rectum or the introduction of 
small pellets of ice into the rectum will relieve straining or 
tenesmus. 

Atomizers are used for sprays and nebulizers where oil 
is the base of the spray. 

Before pouring boiling water into a hot- water bag put 
in a small quantity of cold water. This will prevent 
the seams from spreading. 

For the proper care of milk in the house, see page 397. 

Remember that milk left uncovered for fifteen minutes 
may render all the care and asepsis practised at the dairies 
useless. 

All "can openers" used to open tins of condensed milk 
and buttermilk should first be sterilized by boiling. 

The same care must be taken of condensed milk and 
buttermilk as fresh cows' milk, as infection is just as read- 
ily carried by the one as the other (see page 398). 

Before preparing milk mixtures and before feeding 
children, wash the hands thoroughly. If it is necessary 
to handle anything which might contaminate the hands 
while feeding, rewash them immediately. 

After bottles have been sterilized they should not remain 
uncovered, but immediately stoppered with sterile cotton. 
When the bottles are being filled with milk, do not lay 
this sterile cotton down carelessly and then replace it. 
Keep it sterile. 

All vessels in which milk has stood for any length of time 
must be thoroughly scalded before refilling. 



NURSING IN CHILDHOOD 5 I 

Milk should not be kept warm in Thermos bottles or 
by any other method for any length of time. This applies 
even to pasteurized milk. 

All nipples should be kept in a solution of boric acid 
when not in use. 

To prevent nipples from collapsing, hold the bottle at 
such an angle that the nipple is always filled with milk. 
If for any reason a nipple is removed while the babe is 
nursing, do not put it down carelessly; it is better to drop 
it in a receptacle containing boric acid solution. 

When diarrhea develops, stop the milk immediately. 

A child should never be "jumped up and down" or 
rocked while it is being fed or immediately afterward. 

If there is regurgitation immediately after feeding, sit 
the infant upright. Often there will be an eructation of 
gas which will eliminate this tendency. 

Do not examine a child's throat immediately after feeding. 

Hot-water bottles to a child's feet during bed baths, 
and after all baths, will prevent chills. 

Keep children's feet covered at night; it prevents colic. 

Sudden marked rises in temperature in children who 
have been well should direct your attention to the throat, 
and if no local manifestation of disease is present there, 
the ears should be examined. The ears should be exam- 
ined when children are extremely restless at night and 
when they often cry out suddenly without apparent cause. 

Special attention should be paid to croup, particularly 
to attacks that do not occur at night; it may be laryngeal 
diphtheria. 

In infectious diseases the nurse's sleeves should be rolled 
up above the elbow; in contagious diseases she shoiild 
wear a cap and gown in addition. 



52 DISEASES OF CHILDREN FOR NURSES 

Special attention to the ears and eyes is always necessary 
in measles. Disinfect the sputum and vomitus in cases of 
pertussis. 

Keep children suffering from nephritis and rheumatism 
between blankets while in bed. 

In vaginitis a pad should be worn. 

When shaving the head of girls for a mastoid operation, 
leave a lock of hair in front which can be drawn over the 
scar. It can be retained in place under adhesive plaster 
at time of operation. If the physician gives his consent a 
shampoo before the operation makes the head feel more 
comfortable during the weeks the bandage must be worn. 

When giving lavage and gavage be sure to have some- 
thing between the teeth to prevent the child from biting 
the tube, for if it should be swallowed, it can only be 
recovered by opening the stomach. 

In cases of shock, where nothing is at hand, a pint of 
hot coffee may be injected into the rectum. 

Cradles may be improvised by turning chairs upside 
down. 

If cotton cannot be obtained, newspapers may be sub- 
stituted as a covering for poultices. 

In the country or in houses where the proper facilities 
cannot be procured, a moist atmosphere can be maintained 
by placing hot bricks in a dish-pan half-filled with cold 
water. 

Whenever you are instructed to sterilize a thermometer, 
it should be boiled, but be sure it registers 212° F., else 
it will break. 

Never make a promise to a child unless it can be kept. 

Prophylaxis and Nursing in Contagious Diseases. — 
These are fully taken up under the various diseases. 



NURSING IN CHILDHOOD 53 

Feeding. — Special cases are described under their 
proper headings. Chapters XVII and XVIII fully de- 
scribe feeding during infancy and childhood. 

Treatment is given when an intelligent understanding 
of the underlying reasons are necessary for proper appli- 
cation. As a rule, liquids should be employed. If pills 
or powders are ordered, the physician will usually instruct 
the nurse to crush or dissolve them before administration. 
Some drugs, like salol, however, are not soluble. In 
Chapter XIX the various therapeutic measures employed 
in childhood are described. Nursing of the various dis- 
eases is included in each chapter. 



CHAPTER III 
DISEASES OF THE RESPIRATORY TRACT 

The respiratory tract consists of the nose (rhinos) ; the 
epiglottis; the larynx (glottis); the trachea; the bronchi 
(divided into the large, the medium, the small or capillary 
tubes); the air vesicles; the pleura (a serous membrane 
covering the lungs and lining the chest walls); and the 
mucous membrane lining all of the air-passages. 

In disease of the respiratory tract one or more of the 
follov^ing symptoms is always present: (t) Cough; (2) 
expectoration; (3) dyspnea; (4) accelerated or diminished 
respirations. Pain and fever will be associated with 
these symptoms if inflammation is present. There will 
be an exudate if the inflammation involves a serous mem- 
brane and an abnormal secretion 0} mucus when a mucous 
membrane is attacked. 

Cough is divided into dry, moist, and laryngeal. These 
are also spoken of as hard, loose, and croupy coughs. 

Cough results from all inflammations of the respiratory 
tract; it is heard in certain of the acute infectious diseases 
with which are associated catarrhal conditions of the, 
respiratory tract, such as whooping-cough (pertussis), 
measles (rubeola), and influenza; reflexly, it is caused by 
irritation of the mucous membrane lining the tract and 
by pressure on the recurrent laryngeal nerve. 

Dry cough is a hard, tight cough and has no associated 

54 



DISEASES OF THE RESPIRATORY TRACT 



55 



expectoration. It is seen in the first stages of acute 
bronchitis, in most chest diseases of early childhood, in 
pleurisy, and in reflex cough. 

Moist cough is accompanied by copious expectoration. 
It is seen in the later stages of bronchitis, convalescent 




Fig. is. — Larynx, trachea, and bronchi (Morrow). 

pneumonia, and in most chronic diseases of the respiratory 
tract. 

Laryngeal cough, also termed croupy cough, has a char- 
acteristic hard, barking intonation. It is heard especially 
in laryngitis, spasmodic croup, and whooping-cough. 



56 



DISEASES OF CHILDREN FOR NURSES 



Expectoration results from the abnormal secretions 
of the mucous glands of the respiratory tract. 

Children do not expectorate until after four years of 
age; previous to that time the sputum is swallowed. 




Fig. i6. — Topographic areas of the anterior thorax (Kerr). 

The expectorated material may be mucus or mucus 
mixed with pus (mucopurulent). It may be the so-called 
rusty sputum, referring to its color, due to being tinged 
with altered blood. It is seen in advanced croupous 
pneumonia. Sputum containing fibrinous shreds is seen 
in diphtheria and in fibrinous bronchitis. 

Dyspnea is difficult breathing, with or without increase 
in the number of respirations. It may be present on 
inspiration, expiration, or both. 



DISEASES OF THE RESPIRATORY TRACT 



57 



Dyspnea is caused by any obstruction to the free passage 
of air to or from the lungs. It is also caused by conditions 
which render the air capacity of the lungs less than normal, 
or which in any way interfere with the function of the 
lungs. 



^^PL/o 1-1 



Co V-*\uLa:r 






1 


ular 


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fra- 


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Fig. 17. — Showing the topographic areas of the back (Kerr). 



Orthopnea is the name applied to the posture of a child 
who, on account of dyspnea, has to have the chest elevated 
so that it assumes a sitting or semirecHning position in 
bed. It is usually seen in those suffering from heart 
disease. 

Respiration. — The normal number of respirations 



58 



DISEASES OF CHILDREN FOR NURSES 



per minute varies according to the age of the child. In 
the newborn they are from 30 to 50 per minute; in the first 
year from 28 to 30 per minute; at five years from 22 to 
25 per minute; at 14 years about 20 per minute. The 
ratio between the respirations and the pulse-beats is one 
to four. 




Fig. 18.— Position for examination of back of chest. The child can be perfectly con- 
trolled by the nurse in this position (Kerr). 

Accelerated respirations are noted in fever and in all 
inflammatory diseases of the lungs. 

Diminished respirations are seen in meningitis, in the 
spasmodic affections of the respiratory tract, and in 
uremia. 



DISEASES OF THE RESPIRATORY TRACT 



59 



Cheyne-Stokes respiration is the name given to a peculiar 
form of breathing seen in desperately ill children. It 
is characterized by a cycle. Following an interval, during 




Fig. iq. — Counting the respirations (Kerr). 

which there is no attempt on the part of the patient to 
breathe, the respirations begin slowly; they are deep and 
there is a short period intervening between each breath. 
Gradually they become more and more rapid, and at the 




A/^A^d/^^-jA 



Fig. 20. — Diagram illustrative of normal (upper line) and Cheyne-Stokes respiration 

(lower line) (Kerr). 

same time more shallow, until there is very rapid super- 
ficial breathing. They then gradually diminish in fre- 
quency and become deeper and deeper, the reversal of 
the former phenomena, until they again cease. The 
interval in which there is no attempt at respiration may 



60 DISEASES OF CHILDREN FOR NURSES 

last for thirty seconds. The cycle then begins again and 
goes on indefinitely, usually ending in death. 

RHINITIS 

Rhinitis means inflammation of the mucous membrane 
lining the nose. It is divided into acute rhinitis or coryza^ 
and chronic rhinitis. 

Acute rhinitis or coryza is the ordinary "cold in the 
head." It is due to an acute congestion of the mucous 
membrane lining the nose. The congestion causes 
swelling of the membrane to such an extent that the nasal 
chambers are closed and the patient is forced to breathe 
through the mouth. At first there is no secretion of 
mucus, the only apparent symptom being the general 
sensation of discomfort due to the occlusion of the nasal 
chambers. At the end of about twenty-four or forty- 
eight hours, however, there is a free discharge of mucus, 
very rapidly becoming mucopurulent in character. The 
discharge may cause excoriations of the nostrils and 
upper lip. In infants there is often a slight fever; in older 
children this is not often seen. At times the occlusion of 
the nose and the accompanying discharge is so great in 
infants that it is impossible for them to nurse, and the 
''dropper" has to be resorted to in feeding. Coryza may 
last from two days to two weeks, the discharge gradually 
becoming less and the nasal breathing more easy. 

Treatment and Prophylaxis. — The tendency for some 
children to catch repeated colds is often due not so much 
to poor health as to faulty methods in their habits of 
hving. Children who are kept within doors, in poorly 
ventilated rooms, and are not allowed to go out except in 
pleasant weather, and at such times are overloaded with 



DISEASES OF THE RESPIRATORY TRACT 6 1 

clothing so that any exercise will cause them to perspire 
freely, are the victims of repeated colds. To overcome 
this tendency it is necessary only to enforce proper hygi- 
enic measures. A child should sleep in a room with the 
window open and be given a cold sponge in the morning. 
They should be allowed to play in the open air, except 
when inclement weather prevents. They should wear 
flannels covering their bodies and limbs all year; of light 
texture in summer and heavier in winter; and should 
have only the amount of clothing upon them which is 
seasonable. 

As adenoid growths in the pharynx also predispose to 
repeated colds, they should be removed. 

Abortive treatment for an acute coryza consists in giving 
the child hot drinks, such as lemonade, and a laxative. 
A warm bath (115° F.) is a good adjunct. Profuse per- 
spiration usually follows, which relieves the local con- 
gestion. After a sweat an alcohol rub should be given, 
and the child must remain indoors for the subsequent 
twenty-four hours to avoid taking fresh cold. 

Locally J inhalations of menthol or local applications 
of sweet oil will reheve the congestion somewhat. Anti- 
septic sprays, such as hydrogen peroxid and water, equal 
parts, or normal salt solution will be useful to alleviate the 
discharge when it is established. 

Nasal syringing is described on pages 444 and 445. 

Chronic rhinitis is due to a chronic inflammation of 
the mucous membrane Hning the nose. It is divided 
into simple chronic catarrhal, hypertrophic, and atrophic 
rhinitis. 

A chronic inflammation of the mucous membrane of 



62 DISEASES OF CHILDREN FOR NURSES 

the nose causes an increase in the secretions, so that there 
is a constant discharge, also an impairment of the sense 
of smell. This is easily understood when it is remem- 
bered that the terminal filaments of the olfactory nerve 
are in the highly sensitive mucous membrane lining the 
superior fossae of the nose, and any permanent alteration 
in this membrane has a tendency to impair the function 
of smell. 

Simple Chronic Rhinitis. — The principal symptom of 
this condition is a constant discharge, easily blown out 
of the nose. It is very often due to adenoid growths in 
the pharynx and is attended by excoriation of the nostrils, 
which is aggravated by the constant desire on the part 
of a child to pick its nose. This condition may last for 
years, the symptoms almost disappearing in summer and 
reappearing each winter. Epistaxis or nose-bleed is 
common. 

Treatment and Prophylaxis. — The measures employed 
are hygienic in nature and consist in the child getting the 
proper amount of fresh air and exercise, in cold sponging, 
and in properly clothing the child. Adenoid growths 
should be removed. 

Locally^ antiseptic douching of the nose should be 
practised. Dobell's solution is one of the best remedies. 
When douching the nose in order to rid it of excessive 
secretions, the nostril should not be entirely closed by the 
nozzle of the syringe, leaving sufficient opening for the 
discharge to escape. The syringing must be carefully 
and gently done, so that the material is not forced along 
the Eustachian tube into the middle ear, which would 
give rise to an inflammation. The syringing should be 
done as described on pages 444 and 445. 



DISEASES OF THE RESPIRATORY TRACT 63 

Hypertrophic Rhinitis. — In this variety the mucous 
membrane Hning the nose becomes permanently thickened 
until the chambers are closed, thus forcing the patient to 
breathe through the mouth. This permanent thickening 
causes an impairment of the sense of smell and an over- 
activity of the folHcles of the mucous membrane, which 
produces an increase in secretion. In addition there is 
a general catarrhal condition of the surrounding parts, 
with its attending symptoms, such as deafness from exten- 
sion of the catarrhal inflammation along the Eustachian 
duct into the middle ear, watering of the eyes from occlu- 
sion of the lacrimal duct, and constant clearing of the 
throat from catarrh of the pharynx. This condition is 
infrequent in children. 

Atrophic rhinitis is rarely seen in children under twelve 
years of age. It is the opposite from hypertrophic rhinitis, 
in that the mucous membrane, instead of becoming 
thickened, is found to be thinned and stretched out, and 
the nasal chambers, instead of being occluded, are enlarged. 
There is an atrophy of the tissues of the nose. In this 
condition there is a very ofi^ensive discharge and the 
patients are pale and anemic. 

EPISTAXIS 

Epistaxis or nose-bleed, while not often seen in infancy 
and early childhood, is quite common in older children. 
It may be due to some local condition of the nose, such as 
an excoriation of the septum. It must be remembered 
that nose-bleed is also a symptom of incipient typhoid, 
malaria, and measles, and that it is seen in nasal diph- 
theria and following a paroxysm of whooping-cough. 
More often, however, it is due to a spongy condition of the 



64 



DISEASES OF CHILDREN FOR NURSES 



mucous membrane vrhich is seen in children who do not 
get the proper amount of fresh air and are over-dressed 
when exercising. This relaxed condition of the mucous 
membrane makes them liable to frequent spontaneous 
nose-bleeds. The blood usually flows from one nostril 
drop by drop and lasts from ten to twenty minutes, the 
total amount lost being small. 

Treatment. — Children subject to nose-bleed should get 
plenty of fresh air, be properly dressed, and receive cold 
sponging in the morning. 

During an attack the child should sit upright in a chair, 
the clothing should be loosened about the neck, firm 
pressure made over the bridge of the nose by holding it 
between the fingers, and ice should be applied to the 
bridge of the nose and the back of the neck. Small pellets 
of ice may be introduced into the nostrils or held in the 
mouth. If this does not give results, plugging of the 
nostrils with absorbent cotton may be resorted to. Com- 
pound tincture of benzoin, or lemon-juice, diluted, may 
be introduced into the nose. No astringent powders 
should be used locally on account of their tendency to 
produce sneezing, thus starting the nosebleed afresh. 

LARYNGITIS 

Laryngitis is divided into acute catarrhal, chronic 
catarrhal, syi)hilitic, and tubercular. 

Acute catarrhal laryngitis is an acute inflammation 
of the mucous membrane of the larynx. In this condition, 
as in anv form of acute inflammation of a mucous mem- 
brane, there is congestion and swelling of the tissues. 
The vocal cords are involved, producing hoarseness, the 
characteristic laryngeal, croupy cough, which is worse 



DISEASES OF THE RESPIRATORY TRACT 65 

at night, and often there is pain on swallowing. These 
symptoms last from three or four days to a week, with 
a strong tendency to relapse. 

Chronic catarrhal laryngitis, as in all forms of 
chronic inflammation of a mucous membrane, is char- 
acterized by the permanent thickening of the laryngeal 
tissues due to an overgrowth of connective tissue. This 
produces a tickling in the throat, huskiness of the voice, 
expectoration of thick, ropy mucus, and fatigue and pain 
after moderate use of the voice. 

Tubercular laryngitis is rare in childhood. It follows 
tuberculosis of the lung, but at times it is primary. It is 
manifested in the form of a sluggish ulcer causing deep 
destruction of the vocal cords and consequent loss of 
voice. 

Syphilitic laryngitis is rare in childhood. It may result 
in hoarseness, loss of voice, and stenosis of the larynx. 

Treatment. — In laryngitis, inhalation of steam medi- 
cated with compound tincture of benzoin is always effica- 
cious. In severe cases a croup tent may be used (see page 
446) . Cold compresses applied to the throat often control 
the cough. 

SPASMODIC CROUP 

This is the ordinary croup of childhood. It is caused 
by a spasm of the vocal cords which is excited by a con- 
gestion or a catarrhal inflammation of the mucous mem- 
brane of the larynx. 

The most frequent exciting causes are exposure to cold 
and damp weather, indigestion, and constipation. Any- 
thing which may cause a mild catarrhal inflammation of 
the mucous membrane of the larynx can be the exciting 
cause of croup, for it is this congestion or inflammation 
5 



66 DISEASES OF CHILDREN FOR NURSES 

wliich produces the spasmodic condition of the muscles 
of the larynx. The adductor muscles are the ones most 
involved. 

Symptoms. — The attack occurs in young children 
between the ages of six months and five years. The child 
may have a little hoarseness and coryza during the day, 
and in the evening a laryngeal cough, hard and barking 
in character. The true attack of croup does not occur 
until several hours after the child has gone to sleep. It 
is awakened by severe paroxysms of coughing and by 
difficulty in getting its breath due to the closure of the 
larynx by the spasm of the vocal cords. In a severe case 
there is a marked dyspnea, the breathing is slow and 
labored, and the inspiration noisy, owing to the air whis- 
tling through the narrow opening between the cords. This 
stridulous breathing, as it is called, may be loud enough 
to be heard in the next room. All the symptoms of 
profound dyspnea are present: the nostrils dilate with 
each inspiration, the face is anxious, drawn, and beaded 
with perspiration, the lips and the tips of the fingers are 
slightly blue. The notches above the sternum and the 
clavicles are deeply depressed and the base of the chest 
retracted with each inspiration. All the muscles of 
respiration are brought into play and are very prominent 
from the effort to fill the lungs with air. The pulse is 
rapid, no to 120 beats per minute, and the skin is hot. 
Associated with these symptoms is the hard, metallic, 
croupy cough which at times may almost be incessant. 
The attacks last from a half hour to three hours. The 
cough gradually subsides, the breathing becomes less 
difficult, the child breaks into a free perspiration and 
falls asleep. The attack may recur on the same night. 



DISEASES OE THE RESPIRATORY TRACT 6/ 

The next day, with the exception of sHght hoarseness, the 
child seems perfectly well. The following night, however, 
there is often another attack of croup similar to the first 
and equally as severe, unless proper medical treatment 
has been instituted. The third night, also, may be 
attended with an attack which is not apt to be as severe 
as the preceding seizures. 

Treatment and Prophylaxis. — As the attacks are ex- 
cited by mild catarrhal inflammation of the larynx, such 
defects as may predispose to this condition should be 
remedied. Hypertrophied tonsils and adenoids should be 
removed. Children should have plenty of fresh air and 
cold sponging. Constipation and indigestion should be 
avoided. 

Treatment oj the Attack. — A sponge moistened with hot 
water may be applied to the throat or the child may be 
put in a hot bath or a mustard tub (iio° F.). If these 
simple remedies fail, an emetic will often bring relief, the 
best being the wine of ipecac administered in dram doses 
until effective, or a little powdered alum mixed with honey 
or molasses given in teaspoonful doses. In severe cases 
it may be necessary to resort to the inhalation of chloro- 
form. The object of this plan of treatment is to relieve 
the spasm of the vocal cords. 

A croup tent is a valuable adjunct to this plan of treat- 
ment (see page 446), the moist atmosphere soothing the 
inflamed mucous membrane and thus shortening the 
attack; it also diminishes the chances of recurrence. The 
steam may be medicated with compound tincture of 
benzoin, which increases the efhciency of this plan of treat- 
ment. 



68 DISEASES OF CHILDREN FOR NURSES 

LARYNGISMUS STRIDULUS 

Laryngismus stridulus, also called child crowing, is 
purely of nervous origin (a neurosis), and does not depend 
upon a catarrhal condition of the larynx, Hke spasmodic 
croup. It is due to a complete spasmodic closure of the 
larynx, making it impossible, for a time, for the child to 
breathe at all. The spasm then relaxes and the air is 
drawn through the contracted larynx with a shrill, crowing 
sound. It is seen in children of a rachitic tendency 
between the ages of six and eighteen months and seems 
to be more common in males than females. 

The attacks are frequently seen in children who have 
been closely confined in warm, stuffy rooms, and are often 
associated with enlarged tonsils and adenoids. The 
attack may be excited by a sudden draught of cold air, or, 
reflexly, from teething and gastro-intestinal disorders. 

Symptoms. — The child may have a few mild attacks 
during the day or extending over a period of several days. 
This condition is very often confounded v^th whooping- 
cough, the "crowing" of the mild attacks closely simu- 
lating the whoop of pertussis. 

When the attack is fully developed the child is awakened 
from sleep by a sudden arrest of the breathing and a tonic 
spasm of the muscles. (Tonic spasms are continuous 
spasms in which the patient remains rigid until the spasm 
relaxes.) The face is at first pale and later bluish, the 
neck rigid, the eyes rolled up, the body arched, the thumbs 
turned into the palms of the hands, the legs extended, and 
there is a complete absence of breathing. In about fifteen 
or twenty seconds the spasm relaxes and the air is drawn 
through the larynx with a shrill, crowing sound. At 
times the spasm is longer, and in a few instances asphyxia 



DISEASES OF THE RESPIRATORY TRACT 6g 

has resulted before it has relaxed. Several such attacks 
may occur on the same night, and, gradually decreasing 
in severity, they may extend over a period of one to two 
weeks unless proper medicinal measures are instituted. 

To distinguish this affection from spasmodic croup 
remember that in laryngismus stridulus there is no croupy 
cough, hoarseness, or fever, but there is present a tonic 
spasm and the pecuHar crowing sound. 

Treatment and Prophylaxis. — Fresh air and cold 
sponging unless the shock of the sponging frightens the 
child into an attack ; the rachitis should be treated ; hyper- 
trophied tonsils and adenoids should be removed, and 
gastro-intestinal disorders corrected. 

For the attack the best treatment is to dash cold water 
on the face and neck, in an attempt to break the spasm. 
Mustard tubs (iio° F.) may be resorted to, and inhalations 
of chloroform in severe cases. At times it is necessary to 
perform intubation. 

HOLDING-BREATH SPELLS 

This condition begins in early infancy and may con- 
tinue until the child is four or five years old. 

It is of nervous origin and in susceptible children tem- 
per or fright may precipitate an attack. It occurs while 
the child is crying, when it suddenly holds its breath 
until its face becomes livid, the trunk and extremities are 
rigid, and there may be convulsive twitchings. The 
rigidity is followed by complete relaxation and often loss 
of consciousness. 

The entire attack usually lasts about one-half minute. 
There may be a crowing sound as the child catches 



70 DISEASES OE CHILDREN FOR NURSES 

its breath. After a few minutes of quiet the child ap- 
parently is as well as ever. 

While these attacks are alarming, they never seem to 
be followed by any serious complications, and as the 
child gets older they gradually cease. 

Treatment consists in the adoption of measures to 
break the attack, and the same methods should be fol- 
lowed as described under laryngismus stridulus. Arti- 
ficial respiration is useful, for after the child is breathing 
normally recovery is quick. 

EDEMA OF THE GLOTTIS 

This is a rare condition in childhood. It is dropsical in 
character, due to a serous infiltration into the submucous 
tissues of the larynx. It occurs sometimes in the course 
of scarlet fever, diphtheria, and facial erysipelas. It 
may occur abruptly in the course of Eright's disease. 

Symptoms are those of suffocation due to the swelling 
of the tissues lining the larynx and to the consequent 
closing of the passage. It demands the immediate atten- 
tion of a skilled physician, intubation being necessary in 
many cases. 

BRONCHITIS 

This is an inflammation of the mucous membrane 
lining the bronchial tubes. 

The three main divisions are acute bronchitis^ chronic 
bronchitis, and fibrinous bronchitis. 

Acute bronchitis presents such a difference in the 
grade of severity with which it attacks children that it is 
necessary further to subdivide it for comprehensive study. 



DISEASES OF THE RESPIRATORY TRACT /I 

In children under two years of age bronchitis is always 
serious, hence we divide it into bronchitis of the very 
young, two years and under, and bronchitis of children 
over two years of age. 

The reason that bronchitis is such a severe affection in 
the very young is on account of its tendency to extend 
into the smaller bronchi and verge upon pneumonia. 

The smaller the caliber of the tube affected, the more 
severe the attack of bronchitis. Therefore, it is also 
subdivided into bronchitis of the large tubes, bronchitis of 
the medium-sized tubes, and capillary bronchitis, or, as 
it is usually termed, bronchopneumonia. 

Symptoms in the mild form, or bronchitis of the larger 
tubes in a child under two years of age. Here the respi- 
rations will average about forty or fifty to the minute. 
The temperature ranges from ioo° F. to 102° F. There 
is cough, hard and tight in character at first, but rapidly 
becoming loose. While the cough may be loose in char- 
acter there is no expectoration. Children rarely expec- 
torate before four years of age; previously the mucus is 
swallowed; sometimes this causes vomiting. There is 
some dyspnea and often a co-existing catarrhal condition 
of the nose and throat. 

An attack of bronchitis lasts about a week. In children 
subject to colds, who develop a bronchitis during the 
winter months, the attacks are liable to recur until warm 
weather. 

In the severe jorm, or bronchitis of the medium-sized 
tubes in a child under two years of age, the symptoms can 
hardly be distinguished from pneumonia. The onset, 
however, is not so abrupt, and the temperature does not 



72 



DISEASES OF CHILDREN FOR NURSES 



remain high so long. The attacks last three or four days 
and are accompanied by constitutional symptoms, such 
as prostration, apathy, and loss in weight. In this form 
of bronchitis there is always danger of an extension of 
the inflammation to the capillary tubes. 

Capillary bronchitis is bronchopneumonia, and will be 
considered under that title. 




Fig. 21. — Diagram of bronchial terminations: a, Smaller bronchus ; 6, terminal bron- 
chus ; c, alveolar duct ; d, constriction, or neck ; e, space of infundibulum outlined by 
dotted lines ; /, infundibula ; g, ciliated columnar cells lining small bronchus ; h, nonciliated 
columnar cells lining alveolar ducts ; i, flat epithelium lining alveoli (Leroy). 

In children over two years of age bronchitis is not so 
severe an affection, although here we find the same con- 
ditions existing as in younger cliildren; namely, a mild 
form due to an inflammation of the larger tubes and a 
severe form due to an inflammation of the smaller 
tubes. 



DISEASES OF THE RESPIRATORY TRACT 73 

Symptoms of acute bronchitis in children over two years 
of age consist in chilliness, malaise, some fever, cough, and 
dyspnea. The cough is worse at night; at first it is dry 
and painful, but later becomes loose and is accompanied 
by free expectoration of mucopurulent sputum. Children 
often complain of soreness and pain in the chest dur- 
ing an attack of bronchitis, which is aggravated by 
coughing. 

Treatment.- — Abortive. — A case of incipient bronchitis 
can be aborted by hot foot-baths, the application to the 
chest of a turpentine stupe or a mustard plaster to relieve 
the congestion of the bronchial mucous membrane, and 
the internal administration of hot drinks. A warm 
bath (115° F.) is a good adjunct. Profuse perspiration 
occasionally follows, which relieves the local congestion. 
After a sweat an alcohol rub should be given, and the child 
should remain indoors for the subsequent twenty-four hours 
to avoid taking fresh cold. A laxative is always a safe 
adjunct to this plan of treatment. In younger children 
mustard paste applied to the chest for ten minutes and 
covered with a towel will often abort a forming cold. 

Treatment during the course of the attack is aided by 
having the child live in a moist atmosphere. This can be 
accomplished by steam generated by a special apparatus 
or by the heating of a pan of water over a small gas stove 
in the room. Compound tincture of benzoin added to 
the water increases the efficiency of this method of treat- 
ment. An oiled-silk or cotton-batting jacket, as an 
adjunct to the treatment of bronchitis in children, is at 
times employed. 

In severe cases of bronchitis children sometimes have 



74 DISEASES OF CHILDREN FOR NURSES 

an attack of suffocation and respiratory failure. The 
indications here are to remove any obstructing mucus, to 
compel the child to take deep respirations, and to get as 
much blood to the surface and into the extremities as 
possible, in order to relieve the overloaded right heart. 
Inverting the child will often cause the mucus to run from 
the mouth, and a mustard tub (iio° F.) will accomplish 
the rest. Oxygen and heart stimulants must be given in 
these emergencies. 

In the milder forms of bronchitis the children should 
be confined to the house, but not necessarily to bed. In 
the more severe attacks it is better to put the child to bed, 
and in the very severe cases it should be placed in a croup 
tent. 

Nursing. — The sleeping-room of the infant must not 
be too cold, never below 60° F. It should be well venti- 
lated, receiving a thorough airing two or three times a 
day. An open fire is a good adjunct. 

Hot baths, at a temperature of 110° to 115° F., are fre- 
quently ordered. 

The clothing should be warm, the night-dress of flannel, 
and the feet should be protected against cold. The bed- 
covers should never be tucked lq too tightly. 

The mouth and nose should be kept clean with anti- 
septic sprays and douches, all mucus should be cleared 
from the throat, and the chest thoroughly rubbed with 
camphorated oil. or a similar counterirritant. At times the 
chest may be enveloped in a cotton or oiled-silk jacket. 

A few drops of glycerin undiluted or a small lump of 
sugar will frequently control a severe attack of cough- 
ing. 



DISEASES OF THE RESPIRATORY TRACT y$ 

Cold compresses appKed to the throat will also give 
relief. 

The child should be allowed to sleep as much as it 
will, but should be awakened for its food and medicine 
at regular intervals. It is always best, when possible, 
to combine these two periods, to avoid unnecessary dis- 
turbance. 

Infants can be held in the arms and older children can 
be about the room, unless fever is present. 

The temperature, pulse, and respirations should be 
taken twice a day, unless the temperature is over ioi° F., 
when it should be taken every three hours. 

Chronic bronchitis is caused by repeated attacks of 
acute bronchitis following one another so closely that the 
mucous membrane does not become entirely normal 
between attacks, each one leaving something behind. 
This causes the mucous membrane to become thickened 
by an overgrowth of connective tissue, as in all chronic 
inflammations. 

Symptoms. — A chronic cough which is worse at night 
and expectoration which is most profuse upon arising in 
the morning are the main symptoms. The children are 
pale and thin, but do not become emaciated. 

Fibrinous bronchitis is a rare disease in childhood. 
It is sometimes seen associated with diphtheria, when it is 
due to an extension of the membrane into the bronchi. 
At other times it is unassociated with that disease and is 
due to an inflammation of the bronchial mucous membrane 
and characterized by the formation of a false membrane. 
This membrane is dislodged by coughing and expectorated 
as little whitish balls, which, when unrolled under water, 



76 



DISEASES OF CHILDREN FOR NURSES 




Fig. 22. — Large bronchial coagulum; chronic fibrinous bronchitis (Vierordt). 

present the mold of the branching and ramification of the 
bronchial tubes affected. Acute and chronic forms are 
recognized. 








Fig. 23. — Bronchiectasis: c, saccular; 6, cylindric; one-half natural size (Orth). 



BRONCHIECTASIS 

Bronchiectasis is a dilatation of a bronchial tube. The 
whole tube may be involved or only a small portion may 



DISEASES OF THE RESPIRATORY TRACT yy 

be affected. It is caused by a weakening of the walls of 
the bronchi from inflammation. While in this weakened 
condition cough causes the stretching and dilatation. It 
may produce a cyHndric or a sacculated enlargement of 
the tube. 

ASTHMA 

Asthma is a paroxysmal dyspnea, due to a spasm of 
the bronchial tubes or to a swelling of the mucous mem- 
brane Hning them. In children it is associated with 
marked catarrhal symptoms. 

In young children true asthmatic attacks are not often 
seen, the condition resembles a severe bronchitis with an 
asthmatic tendency; that is, there are catarrhal symptoms 
present, with difficult, wheezing expiration. Such an 
ilkiess may persist for three or four weeks. 

Attacks resembhng asthma in adults do occur in child- 
hood, usually in older children. 

Symptoms. — In those subject to asthma the attack 
may be excited by a cold draught, the inhalation of dust, 
and by an overloaded stomach. The paroxysms appear 
suddenly and especially at night. There is such intense 
dyspnea that the patients have to sit upright with their 
arms in such a position as to bring into play all the muscles 
used in respiration. The respirations are not necessarily 
fast, but they are labored, and there is a loud, noisy, 
wheezing expiration. Cough is often present. Several 
attacks may occur in the course of a few days or they may 
be a month or more apart. 

Treatment. — During the attack prompt rehef often 
follows the inhalation of a few drops of chloroform or 
amyl nitrite. 

Asthmatic attacks occurring in the course of cardiac 



78 DISEASES OF CHILDREN FOR NURSES 

or renal disease are named cardiac asthma and renal 
asthma^ respectively. 

Hay Asthma or Hay Fever. — In this condition, besides 
the asthmatic attacks, there is a coryza and a catarrhal 
condition of the nose and throat. 

Hay fever is seen in the Spring and in the Fall, WTien 
it begins in May or June it is spoken of as rose cold. This 
lasts until the end of July. The time when hay fever is 
most prevalent is in the Fall. It makes its appearance in 
August and continues until the first frost. A peculiarity 
about hay asthma is that it is excited by the poUen of 
plants. 

PULMONARY EMPHYSEMA 

Abnormal distention of the lungs with air may result 
from two causes. The first to be considered is known as 
compensatory emphysema. 

Compensatory emphysema is not a diseased condition 
of the lung affected; it is an extra expansion of the air-cells 
to accommodate more air. There is a certain amount 
of work to be done by the lungs at all times. Although 
a number of air-cells may be disabled from some cause, 
such as consolidation from pneumonia or pressure from 
a pleural effusion, the amount of work does not diminish; 
therefore, it is necessary for the healthy air-cells to distend 
and perform not only their own task, but also that which 
should be done by the diseased area. Consequently, 
these cells have a greater capacity for air than they did 
when all the lung structures were performing their normal 
functions. If the disablement persist, the compensatory 
enlargement is permanent. 

Pathologic Emphysema. — The other cause is purely 
a pathologic condition in which we have a permanent 



DISEASES OF THE RESPIRATORY TRACT 79 

distention of the air vesicles from stretching and thinning 
of their walls. 

Causes. — These include cough, asthma, whooping- 
cough, laryngismus stridulus, and bronchitis. In such 
conditions there is some resistance to the free exit of air 
from the lungs and it requires a certain amount of extra 
effort on the part of the lungs to force the air out. This 
extra exertion falls upon the walls of the air vesicles and 
the strain causes them to stretch. Any condition where 
the walls of the air vesicles have to stand the strain of 
forcing the air out of the trachea is likely to cause 
emphysema. 

Pertussis is the greatest cause of emphysema in 
childhood; the condition usually disappears, however, 
with the paroxysms of cough. 

Symptoms. — There is great shortness of breath on 
account of the damage to the walls of the air vesicles. The 
distention and the loss of resiliency makes the effort to 
empty the lungs of inspired air very difhcult, renders 
expansion impossible, and the chest immobile. The 
typical barrel-shaped chest seen in adults is not common 
in childhood. 

Compensatory emphysema does not produce symptoms. 

Emphysema occurs in young children on account of 

their undeveloped condition and because the lung tissues 

are not strong enough to withstand sudden and violent 

strains. 

HEMOPTYSIS 

Hemoptysis is the name applied to the spitting of blood. 
The blood is ejected by coughing, is bright red in color, 
and frothy; it is mixed with sputum, and the subsequent 
expectorations are tinged with blood. 



8o DISEASES OF CHILDREN FOR NURSES 

PULMONARY EDEMA 

Edema of the lungs is an effusion of serous fluid into the 
air vesicles and into the interstitial tissue of the lung. 

Pulmonary edema is a common cause of death in many 
acute and chronic diseases which end by heart failure and 
the accumulation of blood in the lungs. At the termina- 
tion of a disease which ends by heart failure the heart-beats 
gradually become weaker and weaker, the blood-current 
becomes slower and slower, and as the pressure within the 
arteries becomes less from the failing force of the heart, 
there is a leaking of the blood-serum through the walls 
of the blood-vessels into the air-cells which they surround, 
or into the tissue of the lung itself. This gradually 
continues until the accumulation of fluid practically fills 
the entire lungs, and death results. 

Treatment. — If this condition should arise in the 
course of an acute illness such as pneumonia, the physician 
will probably order heart stimulants to be given imme- 
diately, especially strychnin, -^ gr., and digitalis, 3 to 5 
minims, hypodermically, the doses being for a child of 
four years. In addition, some form of counterirritation 
should be applied to the chest at the same time in order 
to draw as much blood to the surface as possible. The 
best counterirritant is dry cups or a mustard plaster. 
Oxygen should be administered. 

ATELECTASIS 

The absence of air from a portion of the lung due to 
collapse of the air vesicles. 

It may be congenital — due to deficient respiration. 
Children of low vitality, and especially premature babies, 
do not expand their lungs sufficiently, owing to feeble 
efforts at breathing. The air vesicles which are not fully 



DISEASES OF THE RESPIRATORY TRACT 8 1 

expanded by the inspired air collapse, preventing any air 
from gaining access to such areas. 

In order to overcome any tendency in this direction it 
is necessary to see that young children expand the whole 
of their lungs. The best way to accomplish this is to 
have the baby cry with vigor once or twice a day, and 
not allow it to remain perpetually in its crib. A certain 
amount of handling daily is necessary and overcomes the 
tendency toward shallow respiration. 

Atelectasis may be acquired by the occlusion of a bron- 
chus from some cause or other, or it may result from the 
pressure of a tumor or pleural effusion compressing portions 
of the lung. 

PLEURISY 

This is an inflammation of the serous membrane cover- 
ing the lungs. 

In children pleurisy may be dry or there may be an 
ejjusion. The effusion consists of a collection of fluid 
in the pleural cavity which is poured out by the inflamed 
serous membrane. It is composed of serous fluid and 
flakes of lymph. Such a collection of fluid is termed a 
serous ejjusion. This effusion may be purulent in charac- 
ter, when it is termed an empyema. 

Serous effusions are less common in children than in 
adults; under three years of age this form is not seen. 
Empyema, however, is much more frequent in childhood 
than in adult life. 

Pleurisy may involve one side of the chest, when it is 
termed unilateral pleurisy, or it may attack both sides of 
the chest, bilateral pleurisy. 

A sacculated pleurisy is the term applied to a liquid 
effusion in the pleural cavity which is circumscribed and 



82 



DISEASES OF CHILDREN FOR NURSES 



confined to pockets formed by adhesions. In all pleurisies 
there is a deposit on the membrane of a butter-like exudate 
of fibrin; this may form adhesions {adhesive pleurisy). 
These adhesions subdivide the pleural cavity into small 
pockets or they may completely separate one portion of 
the cavity from another by extending across from the 
costal to the pulmonic surfaces. 




Fig. 24. — Diagram of pleural cavities : a. Ribs ; b, costal pleura ; c, pleural cavities ; 
d, lungs ; e, diaphragm ; /, pulmonic pleura. 

Chronic pleurisy is an effusion of any nature remaining 
unabsorbed. 

Causes. — Pleurisy in infants is probably caused only by 
extension of the inflammation from the lungs. Through- 
out childhood the most frequent cause is pneumonia. In 
nearly every case of consolidation in the lung there will be 
an inflammation of the pleura over such an area. 



DISEASES OF THE RESPIRATORY TRACT 83 

Pleurisy is also seen in connection with tuberculosis. 
It is secondary to scarlet fever, typhoid fever, measles, 
and influenza, occasionally. In older children it may 
be due to rheumatism, and at times, though rarely, to 
cold and exposure. 

Pleurisy is most often seen between the ages of one and 
five. It is more common in boys than in girls. 

Pathology. — In the first stages of the attack the mem- 
brane becomes congested and is covered with a thin film 
of lymph. If the process now ceases, it is termed a dry 
pleurisy. This is the usual type in children under seven 
years of age. If the inflammation continues, an effusion 
will form, composed of straw-colored serum with flakes 
of lymph floating through it. The quantity may range 
from a few ounces to several pints, which in favorable 
cases is gradually absorbed. In large effusions the organs 
are displaced and the lungs compressed. 

Symptoms. — Dry pleurisy. — The principal symptoms 
are pain in the side, increased by inspiration, and a dry 
cough, partially suppressed on account of pain. The 
patient lies on the affected side to keep it as quiet as' 
possible, and also to allow the other side to fully expand. 
There is some fever, ranging from 102° F. to 103° F. 
The symptoms continue until the inflammation subsides. 
Adhesions may form and cause some retraction of the 
affected side. 

Serous Pleurisy. — The symptoms resemble pleurisy in 
the adult. At first there is a typical picture of a dry 
pleurisy, with its accompanying symptoms. To this is 
added, on the third or fourth day, the signs of an effusion 
consisting of bulging of the interspaces of the chest, the 
relief from pain as the inflamed surfaces are separated by 



84 DISEASES OF CHILDREN FOR NURSES 

the accumulation of the fluid, and the appearance of 
cyanosis and dyspnea. The ordinary effusion is absorbed 
in a week or ten days, but at times it persists from delayed 
resolution for a much longer period. 

Treatment. — This is the same in dry and serous 
pleurisy. It consists in the appHcation of counterirritants 
and hot poultices for the pain. Sometimes strapping the 
side with strips of adhesi^^e plaster will give relief. The 
physician will order heart and respiratory stimulants, such 
as strychnin, atropin, digitalis, and nitroglycerin, to be 
given hypodermically in case of emergency. At times it 
is necessary to aspirate the collection of fluid. 

Nursing. — The room should be kept at an even tempera- 
ture of 68° F. and be well ventilated. Bathing should be 
restricted to sponging. The clothing should be flannel 
and protection of the feet is necessary. The bed covers 
should never be tucked in too tightly. 

Sleep is often disturbed by pain, so that some counter- 
irritant may be required to give relief. 

Feeding should be at regular intervals. 

The patient may be allowed to sit up after the fever 
subsides, but in large effusions exertion must be avoided, 
as sudden death has taken, place under such conditions. 

The temperature, pulse, and respirations should be 
taken every three hours as long as there is fever; later, 
twice a day is sufficient. 

As primary cases of pleurisy are often tubercular, extra 
care must be taken with this form of the disease. 

If the child's chest is tapped, a specimen of the fluid 
should be collected in a sterile test-tube with an aseptic cot- 
ton stopper. Disinfect the remainder before disposing of it. 

Empyema or purulent pleurisy is common in children. 



DISEASES OF THE RESPIRATORY TRACT 8$ 

It is most often a sequel of pleuropneumonia. After 
seven years of age it sometimes occurs in connection with 
tuberculosis. It also is a complication of scarlet fever, 
measles, and any of the acute infectious diseases. 

Pathology. — In empyema the pleural cavity is filled 
with thick, non-offensive, greenish-yellow pus, amounting 
from a half pint to two pints. The left side is more 
commonly affected than the right, and at times it is 
bilateral. 

Symptoms. — Following one of the acute infectious 
diseases there is an effusion found in the pleural cavity 
which does not show signs of absorbing. Before seven 
years of age any pleural effusion must be looked upon as 
the result of empyema, so rarely is serous pleurisy seen 
before that time. 

The child becomes pale and thin, the respirations 
become accelerated, there is fever, but often not of the 
hectic type, as is usually seen when pus is present. (A 
hectic temperature is marked by a very irregular . fever, 
alternating high and low, and is accompanied by sweats 
and chills.) The fluid gradually accumulates and dyspnea 
develops. If left to itself, the purulent effusion may kill 
by sepsis or it may perforate into the lung, the pus then 
being coughed up and expectorated. It sometimes 
perforates into the surrounding organs or tissues, causing 
a local abscess. 

Diagnosis. — If there is any doubt as to the character of 
the fluid in the pleural cavity, this may be cleared up by 
puncturing the cavity with an exploring needle; an ordinary 
hypodermic syringe is used for this purpose. At the point 
selected by the physician for puncturing, after the skin 
has been rendered aseptic by scrubbing with tincture of 



86 



DISEASES OF CHILDREN FOR NURSES 



green soap and alcohol, a sterile needle attached to the 
syringe is plunged through an interspace into the pleural 
cavity and the syringe is slowly filled. The character of 
the effusion will at once be apparent, pus showing as a 
creamy- white fluid. At times the needle may not find pus, 
even when it is present. This may be on account of large 
flakes of lymph obstructing the needle or because the 




Fig. 25. — Apparatus for aspiration (Kerley). 



needle has penetrated too far and gone completely 
through the cavity. Care and repeated punctures will 
usually overcome this contingency. 

Treatment. — After it has been definitely decided that 
the case is one of empyema there are two procedures 
which the physician may follow. In the large number 



DISEASES OF THE RESPIRATORY TRACT 



87 



of cases he will have the child operated upon. In a 
fewer number of cases he will have the pleural cavity 
aspirated. 

Operation. — This consists in opening the pleural cavity, 
removing the pus, and draining. There are several 
methods employed. A simple incision or an incision 




Fig. 26. — Apparatus used after operation for empyema to fully expand collapsed 
lung. One bottle is filled with water which may be colored, the air pressure necessary 
to force water from one bottle to the other causes the lung to expand. Ordinary wide 
mouth bottles may be used if the tubing is applied as in the illustration. 



and the removal of a portion of one or more ribs for 
better drainage are the methods usually followed. A 
rubber tube is inserted into the cavity to insure perfect 
drainage. 

Aspiration is accomplished by plunging a large needle 
or trocar and canula through the chest wall and having 
the instrument used attached by a tube to a vacuum 



88 DISEASES OF CHILDREN FOR NURSES 

pump. This method does not remove all of the pus 
nor the shreds of fibrinous material, and often has to 
be resorted to repeatedly, as proper drainage is not 
established. 

After-treatment. — This consists in methods employed 
to bring about the full expansion of the lungs. For 
this purpose two bottles connected by tubing are used. 
One bottle is filled with water, which may be colored if 
convenient. The child is instructed to blow the water 
from one. bottle into the other. This can be made a 
pastime, and it serves the purpose of expanding the 
lungs. 

Nursing. — The temperature of the room should be 
maintained at 68° F.; ventilation is necessary; bathing 
should be restricted to sponging. 

Sleep and feeding usually are undisturbed. 

The two precautions to be taken by the nurse in dressing 
a case of empyema which has been operated upon are: 
(i) To see that there is no danger of the tube slipping 
through the wound and being lost in the pleural cavity. 
This can be prevented by inserting a safety-pin through 
the end of the tube. (2) To see that the exit of the tube 
is covered with gauze. This covering acts as a valve 
which allows the pus to escape and prohibits air from 
entering. The presence of air in the pleural cavity 
prevents the full expansion of the lungs, which have been 
compressed by the fluid. 

The child should be allowed to move from side to side, 
but should be encouraged to lie on the side where the 
wound is situated, as long as there is any discharge. At 
the end of two weeks the child can sit up. 

A specimen of the pus from the wound should be 



DISEASES OF THE RESPIRATORY TRACT 89 

obtained at the time of the operation and kept in a sterile 
test-tube with an aseptic cotton stopper. 

The temperature, pulse, and respirations should be 
taken every three hours if there is fever. 

The exercise of blowing water from one bottle to another 
should be carried out if the child is able to do it. If this 
fails, blowing soap bubbles is a good substitute. 

Hemorrhagic Pleurisy. — This is a bloody effusion 
into the pleural cavity. After seven years of age hemor- 
rhagic pleurisy is sometimes seen in connection with 
tuberculosis and severe anemias. It is also called hemo- 
thorax. 

Diaphragmatic Pleurisy is an inflammation of the 
pleura covering the diaphragm. In addition to the typical 
symptoms of pleurisy there is apt to be extreme dyspnea 
and hiccough. 

Pleurodynia is the name given to rheumatism of the 
intercostal muscles. The chief symptom is pain in the 
side upon deep inspiration. 

Prognosis of Pleurisy. — This depends largely on the 
character and amount of the fluid present. The aspirating 
needle is a great aid to the physician in settling this 
question. 

In serous pleurisies the outcome is usually good. In 
adhesive pleurisy the outlook is favorable, but there may 
be some subsequent retraction and more or less impair- 
ment of the affected side. When the pleurisy is not a 
complication of an acute infectious disease and arises 
spontaneously in children over seven years of age it is 
usually tubercular in character. In empyema the prog- 
nosis is always grave, but recoveries often follow. 

Hydrothorax is an exudation into the pleural cavity 



90 DISEASES OF CHILDREN FOR NURSES 

of a clear, serous fluid. It is not due to an inflammatory 
condition of the pleura, but occurs in the course of a' 
general dropsic condition of the body. 

Pneumothorax. — Air in the pleural cavity. 

Such a condition is caused by a rupture of the lung 
from any cause into the pleural cavity, allowing air to 
gain access from that source, or by a penetrating wound 
of the side, which forms an avenue of entrance for the 
external air. 

While the first condition may be one of pneumothorax, 
inflammation sets in very early and there is an exudation 
of serum; the condition then becomes pneumohydrothorax. 



CHAPTER IV 

DISEASES OF THE RESPIRATORY TRACT 

(Continued) 

The Lungs 

The lungs consist of air-cells at the termination of the 
small bronchi. On cross-section, as in the illustration, 




Fig. 27. — Section of lung: a, Cross-section of small bronchus; h, alveolus; c, alveolar 
wall lined with flat epithelium ; d, top wall of alveolus entirely cut across ; e, section into 
infundibulum, showing several alveoli opening into it (Leroy). 

they resemble a bunch of grapes. The alveoH or air-cells 
have resiHent walls permitting them to expand and to 
contract. 

91 



92 



DISEASES OF CHILDREN FOR NURSES 



In the thin walls of the air-cells are minute capillary 
vessels which are so arranged that the oxygen from the 
inspired air contained in the alveoh is readily absorbed 
by the blood in the capillaries ; at the same time the carbon 
dioxid (CO2), which is the product of the waste of the 
body, is thrown off from the blood into the air-cells and 
exhaled. This process purifies the blood, changes venous 



Right common 

carotid artery 

Subclavian 

arteries 

Innominate 
artery 

Arch of aorta 
Right lung 

Superior vena 
cava 

Right auricle' 




Larynx 



Trachea 

Subclavian 
arteries 



Left lung 

Pulmonary 
' . artery 



Heart 

Coronary 
artery 



Fig 28. — Relation of lungs to other thoracic organs (Ingals). 



blood into arterial, and is the sole function of the lungs. 

Between the groups of air-cells there is a supporting 
structure of connective tissue. The air vesicles are lined 
with mucous membrane. 

The lungs are divided into lobes: the left lung into two, 
the superior and injerior, and the right into three lobes, 
the superior, the middle, and the injerior. 



DISEASES OF THE RESPIRATORY TRACT 93 

The lungs are covered by the pleura. 

The respirations during childhood vary. In the newborn 
they are from 30 to 50 per minute, in the first year 28 to 30, 
at five years 22 to 25, at fourteen years 20, in adult life 
18 per minute. 

The thin chest walls in childhood give less protection 
to the lungs than those of an adult, consequently children 
are more affected by exposure. A distended stomach 
may embarrass the respiration of a child, owing to the 
high position of the diaphragm. Acute congestion may 
give rise to as severe symptoms as pneumonia, due to the 
small, undeveloped air-cells. 

CONGESTION OF THE LUNGS 

Congestion of the lungs may be active^ passive, or 
hypostatic. 

Active congestion is due to an increase in the flow of 
blood from the heart to the lungs. The arteries become 
engorged and the function of the lungs is restricted. 
Active congestion of the lungs is seen in conditions which 
produce an overactivity of the heart, such as high altitudes, 
excitement, and cardiac hypertrophy. In inflammatory 
diseases of the lungs there is an associated active conges- 
tion. The first stage of croupous pneumonia consists 
in this type of congestion. 

Passive congestion is caused by some obstruction to 
the flow of blood from the lungs to the heart. It is most 
often caused by heart disease; under such conditions the 
heart is so damaged that it is unable to pump the blood 
with the normal force and maintain the necessary speed, 
the current thus becomes dammed back in the great 
vessels of the lungs. 



94 DISEASES OF CHILDREN FOR NURSES 

Hypostatic congestion is seen in diseases which 
require the patients to remain for long periods upon their 
backs. Such protracted illnesses always weaken the 
heart, so that it does not have the power to force the blood 
column through the arteries at the normal speed and 
pressure. This allows the blood current to become 
sluggish, and in the dependent portions of the lungs there 
is a congestion due to an engorgement of the vessels. The 
reason for changing the position of a patient in bed at 
frequent intervals is to overcome this tendency to hypo- 
static congestion. 

Sjrmptoms of congestion consist of cough, dyspnea, 
slightly accelerated respirations, and fever. 

Treatment consists in the appHcation of some form of 
counterirritation to draw the blood from the congested 
lungs to the surface. Dry cups, mustard paste, amber 
oil, camphorated oil, and antiphlogistin may be used. 
An oiled-silk or a cotton-batting jacket at times is worn in 
addition. 

PNEUMONIA 

This term is applied to inflammation of the lungs. 

The main divisions of pneumonia are broncho pneumonia j 
croupous pneumonia, pleuropneumonia, hypostatic pneu- 
monia, and chronic bronchopneumonia. 

Bronchopneumonia is also termed lobular pneumonia, 
meaning that several lobes of the lungs are involved. The 
pneumonic areas are small, they do not occupy a whole 
lobe, and are scattered through several lobes of the lungs. 
It is also termed catarrhal pneumonia. 

Croupous pneumonia is also termed lobar pneumonia, 
meaning that the pneumonic consolidation usually in- 
volves the entire lobe of a lung or at least a part of one. 



DISEASES OF THE RESPIRATORY TRACT 95 

It is sharply circumscribed and there are no scattered areas 
through the other lobes, as in bronchopneumonia. More 
than one lobe may be involved, the disease spreading 
through the additional lobe or lobes in the same manner. 

The term pneumonia 0} the apex is used when the apices 
of the lungs are involved. A rare form of croupous 
pneumonia is double pneumonia, in which both lungs are 
affected, but not necessarily the whole of each. A massive 
pneumonia is an inflammation not only of the air vesicles, 
but also of the bronchi and other lung structures. A 
creeping or migratory pneumonia affects successively 
different lobes of the lungs. Epidemic pneumonia 
involves large numbers of children and seems to be con- 
tagious. 

The contagiousness of bronchopneumonia cannot be 
determined without more complete data than at present 
existing. There seems to be no doubt, from clinical 
observations alone, that the secondary forms, especially 
those that complicate measles and diphtheria, are some- 
times communicated in this way. This is probably not 
often true of primary cases except in hospitals for infants, 
where the rapid development of case after case in the 
same ward cannot be explained upon any other hypothesis 
(Holt). Croupous pneumonia is not contagious. 

Under two years of age bronchopneumonia is more 
frequently seen than croupous pneumonia. The propor- 
tion is 75 per cent, bronchopneumonia and 25 per cent, 
croupous pneumonia. The reason for this is found when 
the structure of the lungs is studied. Before two years 
of age the lungs are undeveloped and their structure is 
mostly bronchial in character. As the child grows the air 
vesicles become more and more developed and the struc- 



96 DISEASES OF CHILDREN FOR NURSES 

ture of the lungs more vesicular in type. Bronchopneu- 
monia is an inflammation of the terminal bronchi ; croupous 
pneumonia is an inflammation of the air vesicles; pneu- 
monia is a common disease at all ages. Therefore, before 
the air vesicles have developed the pneumonia attacks 
the predominating structures, the capillary bronchi, giving 
rise to bronchopneumonia; and later when the air vesicles 
become the principal part of the lungs the pneumonia 
attacks them, giving rise to croupous pneumonia. 

Prognosis. — In childhood croupous pneumonia is rarely 
a fatal disease, while bronchopneumonia causes more 
deaths among infants than any other disease excepting 
infantile diarrhea. In the adult croupous pneumonia is 
one of the most treacherous and fatal diseases that exists, 
the mortality ranging from 20 per cent to 40 per cent, or 
one in every four or five dying, while bronchopneumonia 
is rarely met with as a primary condition. 

The high mortality of croupous pneumonia in the adult 
is principally caused by heart failure occurring during the 
course of the disease. The great vascularity of the lungs 
(the whole amount of blood in the body passes through 
the minute capillaries of the lungs once in about twenty- 
two seconds (Vierordt) ) renders it necessary that there 
should be no obstruction. Normally, the lungs can be 
likened to a sponge. It is easy, under such circumstances, 
for the heart to pump the blood column through the 
unresisting tissues. In pneumonia, however, the structure 
of the lungs becomes like liver. This vastly increases the 
obstruction and the strain upon the heart. In children 
the heart is strong and vigorous and it is able to cope with 
the extra strain, while an adult's heart has not the same 
inherent strength after years of work. In addition an 



DISEASES OF THE RESPIRATORY TRACT 97 

adult has probably ''put on flesh," every ounce of which 
means extra work for the heart (this is the reason that a 
thin person can withstand an attack of pneumonia better 
than a stout one). The ferocity of the disease itself seems 
to be worse in an adult than it is in a child, owing usually 
to lowered vitaHty from overwork and exposure. These 
reasons explain the difference in the mortality of croupous 
pneumonia in adults and in children. 

Pleuropneumonia is much more frequent in childhood 
than in adult life. 

Acute Bronchopneumonia. — Under two years of 
age most cases of primary pneumonia are bronchial in 
type. After two years of age the great majority of cases 
of pneumonia which follow measles, diphtheria, pertussis, 
and influenza are of this variety. The mortality of 
bronchopneumonia in children stands second only to 
gastro-intestinal diseases. It varies greatly, but about 
40 per cent, of the cases die. This is due to the weak 
resisting powers of the undeveloped infant and also to the 
fact that when bronchopneumonia is a secondary condition 
it complicates such diseases as pertussis, scarlet fever, 
diphtheria, and influenza. These already have so weak- 
ened the child's constitution that when pneumonia sets 
in the child is physically unable to cope with the added 
infection. 

Bronchopneumonia is not often seen among the better 
classes as a primary condition. It is a disease due to 
exposure and poor hygienic surroundings. Primary cases 
are usually due to the pneumococcus and secondary cases 
to what is termed a mixed injection. This mixed infection 
may be due to the bacilh causing the disease of which the 
pneumonia is a complication, such as the bacillus of 
7 



98 DISEASES OF CHILDREN FOR NURSES 

influenza and the pneumococcus, or it may be due to the 
presence of the streptococcus and staphylococcus (pus 
organisms). The latter is the usual cause. 

Bronchopneumonia generally begins in the larger 
bronchi, gradually working into the smaller tubes and 
finally involving the air vesicles. It is easier to under- 
stand bronchopneumonia if it is considered as a bronchitis 
of the terminal bronchial tubes and adjacent air vesicles. 
As in bronchitis, there is an inflammation of the small 
bronchial tubes with congestion and swelling of the mucous 
membrane, an over-secretion of mucus, and a shedding 
of the lining epithelial cells. This exudate fills the small 
air-cells adjacent to the inflamed bronchial tube, producing 
a pneumonic consolidation. The presence of the mixed 
infection causes this consolidation, composed of debris, 
to break down and suppurate, and thus pin-point abscesses 
are formed in the pneumonic area. These areas are 
scattered; as the disease extends from the bronchioles, 
only the air vesicles adjacent to the inflamed tubes are 
involved. The most frequent location of the disease is 
in the lower lobes, posteriorly, of both lungs. The healthy 
portions of the lungs are distended to accomplish their 
added task and hence a condition of hypertrophic com- 
pensatory emphysema co-exists. There are no definite 
stages, as in croupous pneumonia. 

Symptoms. — The clinical picture of bronchopneumonia 
is an exceedingly varied one; there is no typical course. 
The symptoms most frequently seen are as follows: 

The symptoms of bronchitis, if present, become slowly 
or rapidly worse and merge into those of pneumonia. 
More often in primary bronchopneumonia the onset is 
sudden, the child is seized with vomiting and high fever. 



DISEASES OF THE RESPIRATORY TRACT 



99 



cough, accelerated respiration, prostration, and cyanosis. 
The temperature is remittent in type. It is high, but has 
wide daily fluctuations of from four to five degrees. This 
high temperature continues for a week or two and then 
falls by lysis. Lysis is a gradual fall of the temperature to 
normal, taking from two days to a week to reach this 
point. In contrast to this, crisis is a sudden drop from 
an exceedingly high temperature to normal within twenty- 
four hours. 



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Fig. 29. — Chart of the temperature ( ) and respkations (- 

Child one year old (Kerr). 



-) m bronchopneumonia. 



Just before death the temperature often reaches 107° F. 
and 109° F. 

The respirations average from sixty to eighty per 
minute, often they are one hundred per minute, and 
occasionally a hundred and twenty. There is great short- 
ness of breath (dyspnea), the child struggles for each 
breath, the chest is retracted at the base, and the other 
symptoms of dyspnea are present. The respiratory action 
is more affected than the heart action, and if the child 
succumbs it is usually by respiratory failure, the symptoms 
of which are very rapid, superficial breathing, sometimes 



100 DISEASES OF CHILDREN FOR NURSES 

a hundred to a minute, blueness of the Hps and finger-nails, 
and often a bluish hue to the body. 

The pulse averages from one hundred and fifty to two 
hundred per minute. When very rapid it is often irregular. 
The character of the pulse is more important than the 
rapidity. At first it is full and strong, but later it becomes 
weak, thready, compressible, and intermittent. 

Cough is always present and very persistent, more so 
than in croupous pneumonia. A good, strong cough is 
not an unfavorable symptom, as it shows that the reflex 
irritability of the bronchial tubes is still present. When 
this is lost the mucus is not removed, the lungs fill up, and 
respiratory failure threatens. Suppression of cough is, 
therefore, a bad sign. 

There is no expectoration before four years of age, the 
mucus is either swallowed or re-inspired. During severe 
paroxysms of coughing, if the child be turned on its face 
or inverted, much of the mucus will run out of the mouth. 

A blueness (cyanosis) of the skin and mucous membrane 
is found in severe cases. It is due to a sudden congestion 
of a portion of the lungs not previously affected. Even 
when present only at lips and finger-tips, the patient 
should be very carefully watched, and if further symptoms 
of respiratory failure develop, they should receive prompt 
treatment (see pages in and 427). 

Prostration is progressive; at first it may be moderate, 
but in the final stages there may be symptoms which are 
known as the typhoid state. These are delirium, picking 
at the bed-clothes (carphalogia), twitching of the tendons 
(subsultus tendinum) rare in childhood, and dry, brown, 
fissured tongue. 

Gastro-intestinal Symptoms. — Often there are from four 



DISEASES OF THE RESPIRATORY TRACT loi 

to six green stools a day, containing mucus and undigested 
food, due to the weakened digestion from the fever and 
induced by feeding improper food. This same condition 
may cause vomiting. Vomiting and diarrhea add much 
to the danger of the attack, and when the result is in doubt, 
may turn the scales against the patient. In summer this 
complication is more frequent and more severe. Disten- 
tion of stomach and intestines from gas may cause attacks 
of cyanosis, which condition should be reHeved as soon as 
possible. The rectal tube may be employed with care. 

The urine is scanty. 

Complications. — Pleurisy is nearly always present. Pur- 
ulent meningitis sometimes complicates acute broncho- 
pneumonia, but the most frequent complications are 
referable to the gastro-intestinal tract. 

Croupous pneumonia is an acute, infectious, inflam- 
matory disease of the lungs characterized by a high fever 
and ending by crisis in from five to nine days. Seventy- 
five per cent of the cases of croupous pneumonia are 
caused by the diplococcus pneumoniae. 

The term lobar pneumonia is generally used for this form 
of pneumonia, so-called on account of its tendency to 
involve a whole lobe of the lung in contradistinction to 
bronchopneumonia, which is sometimes called lobular 
pneumonia. 

Croupous pneumonia is one of the oldest recognized 
diseases ; it was described fairly accurately by Hippocrates 
in 460 I^. C. 

In childhood pneumonia follows, in a general way, the 
character of an attack in the adult. In speaking of 
bronchopneumonia it was said that it was the pneumonia 
of early infancy. This is true until children are about 



I02 DISEASES OF CHILDREN FOR NURSES 

two years of age, after which they are usually attacked 
by croupous pneumonia. This disease has a tendency to 
attack children that were previously healthy; it is especially 
prevalent in the spring of the yearo 

Epidemics are not frequent among children, and the 
disease is rarely fatal. In the order of frequency the 
disease attacks the following portions of the lungs: left 
base, right apex, right base, left apex. 

The comphcations of pneumonia are pleurisy, endo- 
carditis, meningitis, and neuritis. 

Children rarely have complications, the one most often 
seen being empyema, which is probably on account of the 
proneness of children to have severe pleurisy associated 
with croupous pneumonia. The temperature is generally 
higher, the pulse more rapid, the duration shorter, and the 
cerebral symptoms more frequent in children than in 
adults, otherwise, as has been mentioned before, the 
disease is the same. 

The cause of croupous pneumonia is usually exposure. 
The disease occurs more frequently in males than in 
females. It is usually primary, occasionally it will com- 
plicate some form of infectious disease. 

There are four distinct stages in croupous pneumonia: 
The stage of congestion or engorgement, seen in the first 
twenty-four hours. The stage of red hepatization, of 
from four to five days' duration. The stage of gray 
hepatization, of from six to ten days' duration. The stage 
of resolution, of from six to ten days' duration. 

Congestion is the stage in which the lung is engorged 
with blood, yet permeable to air. It is an active conges- 
tion of the lungs. 

Stage of red hepatization. The term hepatization is 



DISEASES OF THE RESPIRATORY TRACT IO3 

given on account of the liver-like appearance of a lung on 
section. In this stage the lung is dark red in color, and 
of very firm consistency. This is caused by the air-cells 
being filled with what is known as a croupous exudate. 
This exudate is composed of red blood-corpuscles from 
the capillaries surrounding the alveoH and exfoHated 
epithehal cells which hne the walls of the air vesicles, all 
massed together by fibrin. The croupous exudate ex- 
cludes the air from the alveoli affected. This gives rise 
to a consolidation of the lung, which normally is permeable 
to air. This condition is called a pneumonic consolidation. 
The size of the area consohdated depends upon the number 
of air-cells filled with the croupous exudate. In croupous 
pneumonia a whole lobe or more is usually affected. It 
can be understood to what extent the function of the lungs 
would be impaired under such conditions, and also the 
tremendous extra strain thrown upon the heart, which 
has to pump the blood through the consolidation just 
as through the normal lung. 

The stage of gray hepatization is so called from the 
appearance of a lung on section. It is grayish and still 
firm and Hver-Hke. The grayness is due to the air-cells 
being filled with white blood-corpuscles, the red blood- 
corpuscles and fibrin having been withdrawn. The 
pneumonic consoHdation still remains, as the affected area 
is still impermeable to air. The whole pneumonic con- 
solidation has become softened in this stage by degener- 
ation, and is in preparation for the stage of resolution. 

The stage of resolution is characterized by the lique- 
faction of the croupous exudate, part of which is expector- 
ated and part absorbed. Resolution generally begins 
when the temperature falls to normal and lasts about a 



I04 



DISEASES OF CHILDREN FOR NURSES 



week. Delayed resolution is the term applied to a slowly 
resolving pneumonia, which may be prolonged from a week 
to a month. 

The pleura adjacent to the pneumonic area is nearly 
always involved. 

Symptoms. — The disease is ushered in suddenly with 
high fever, prostration, acceleration of the respiratory 
rate, and increase in the pulse-beats. In children vomiting 
often attends the onset. Pain in the side is also quite 



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Fig. 30. — Chart of the temperature ( ) and respirations ( ) in lobar pneumonia. 

Child one year old (Kerr). 



common; a decided chill is not as characteristic as it is 
in adults. At times the pain is referred to the region of the 
appendix and appendicitis is simulated. The child appears 
profoundly sick from the beginning. The skin is hot, the 
face flushed, often more so on the side corresponding 
to the pneumonic: consolidation. The temperature reaches 
104° to 105° V, within twenty-four hours. The pulse is 
full and strong, averaging 120 to 130 per minute, the 
respirations are labored and from 40 to 50 per minute, 
which in severe cases may be as high as 80 to 100. The 
signs of dyspnea are present, the breathing is not always 



DISEASES OF THE RESPIRATORY TRACT 105 

regular, and there is a characteristic catch of the breath or 
moan at the end of each expiration. Cough develops 
early and is hard, catchy, and partially suppressed. There 
is no expectoration. The urine is scanty. 

The temperature remains continuously high with 
slight daily fluctuations. Herpes develops on the Hps, 
the child may be delirious, more often at night than at any 
other time. Cyanosis may be present, but it is not nearly 
so frequent as in bronchopneumonia. The danger of 
respiratory failure is practically absent; on the other hand, 
the chances of heart failure are vastly increased. 

In a day or two the cough becomes loose. In children 
under four years of age there is no expectoration, as the 
mucus is swallowed. Older children may have the rusty 
sputum seen in adults. 

The position in bed (decubitus) is also characteristic; 
the patient will He on the side affected to give the sound 
side a chance for increased expansion. Leukocytosis is 
usually present, the white blood-corpuscles being increased 
from 6000 to 19,000 or 20,000 or more, per cmm. 

All these symptoms continue unchanged for from five 
to nine days, when, if recovery takes place, a sudden drop 
in the temperature occurs, often accompanied by free 
perspiration, while a state of comparative comfort succeeds 
to that of great distress, and it may be followed by a long 
and refreshing sleep. This is known as the crisis. It 
may be preceded by a fall of temperature a day or two 
earlier, which is again followed by a rise. If there is a 
fall of this description it is called pseudocrisis. The fall in 
a crisis is sometimes as much as seven degrees in a single 
twenty-four hours, and the minimum is often sHghtly 
subnormal, from which it rises rapidly to the normal. 



I06 DISEASES OF CHILDREN FOR NURSES 

Sometimes the temperature falls by lysis. From this 
point onward convalescence is rapid; in a week the child 
is out of bed and in a month is out of doors. 

Pneumonia either ends in resolution, abscess, gangrene, 
interstitial or fibroid pneumonia, phthisis, or, if fatally, 
usually by heart failure. Abscess from introduction of 
pus organisms; gangrene from engorgement of pulmonary 
vessels; interstitial pneumonia from overgrowth of con- 
nective tissue from exudate becoming organized; phthisis 
from introduction of tubercle bacilli. 

The symptoms of heart failure are coldness of hands 
and feet, then of the legs and arms, a rapid, compressible, 
and sometimes irregular pulse, muscular weakness and 
pallor, but usually no cyanosis. 

Death usually occurs at the time of the crisis, so if the 
child can be kept alive until this time has passed, it is 
practically saved. 

Prognosis. — MortaHty is about 4 per cent. The differ- 
ence from pneumonia in adults is at once apparent when 
it is known that the adult mortaHty is from 20 per cent, to 
40 per cent. When compUcated by meningitis and 
endocarditis it is usually fatal. 

Cerebral pneumonia is a form of the disease character- 
ized by severe nervous symptoms. Convulsions occur 
in about 5 per cent, of the cases, and in the more severe 
forms arching of the back (opisthotonus) may be found. 

Pleuropneumonia. — Children are especially prone to 
have pleurisy, and nearly every case of pneumonia could 
be called pleuropneumonia. Usually under this term 
are included cases with excessive amount of pleurisy, 
the two processes uniting to form a single clinical type 
of disease. There is little to distinguish a case of pleuro- 
pneumonia except the severity of all the constitutional 



DISEASES OF THE RESPIRATORY TRACT 1 07 

symptoms. The temperature is often higher, the prostra- 
tion greater, and the patient in every way impresses one 
as being more seriously ill than with ordinary pneu- 
monia. 

Hypostatic pneumonia, Hke hypostatic congestion, is 
caused by the venous stasis, owing to the child's recum- 
bent position. For this reason the position of a patient 
in bed should be frequently changed. 

Aspiration pneumonia is due to the inhalation of 
some foreign substance into the lungs, which gives rise to 
an inflammation. Such foreign material may be diphtheric 
membrane, food, etc. The symptoms are those of croup- 
ous pneumonia. 

Chronic interstitial pneumonia, as said before, is 
sometimes a sequel to croupous pneumonia, but in children 
it is usually associated with phthisis. It is due to an 
overgrowth of fibrous tissue, with subsequent retraction 
of the lung tissues. It is generally characterized by 
chronic cough, sHght dyspnea, and scanty expectoration. 
Bronchiectasis sometimes results when there is the char- 
acteristic fetid sputum, which occurs in gushes. 

Gangrene of the lung is sometimes seen following 
pneumonia. The bacteria of putrefaction gains access to 
the diseased area and cause necrosis. It is fatal. 

Symptoms. — Children have the characteristic symptoms 
of inflammatory disease of the lungs, such as cough and 
dyspnea, together with profound prostration and the 
expectoration of very offensive sputum. 

Abscess of the lungs is more common than gangrene. 
Small abscess may be seen in bronchopneumonia. Some- 
times an empyema {purulent pleurisy) will rupture into 
the lungs, causing a secondary abscess. 



I08 DISEASES OF CHILDREN FOR NURSES 

The symptoms here will be those of any lung affection 
(fever, cough, dyspnea, and expectoration) plus the 
characteristic symptoms of pus, namely high and irregular 
fever, rigors, sweats, and pallor. 

Embolic septic pneumonia or a metastatic abscess of 
the lung is caused by a septic embolus. Such a septic 
embolus may arise at the seat of some putrid inflammation 
or suppuration, such as a wound of an operation or a 
compound fracture. This embolus lodges in the small 
capillaries of the lung and starts a point of suppuration, 
from which there will arise all the symptoms of pus. It is 
generally only one of the lesions of pyemia. 

Treatment. — Pneumonia, both bronchopneumonia and 
the croupous form, are diseases which for a favorable 
outcome depend not so much on the remedies given as 
upon the general hygienic measures employed. These 
measures are grouped under the term general nursing. 
Since in the treatment of bronchopneumonia very Httle 
can be done for the disease and very much can be done for 
the patient, and since croupous pneumonia is a self-Hmited 
disease having a strong tendency in childhood to recovery 
regardless of the treatment adopted, the plan of treatment 
of both diseases is practically the same. 

Serum Treatment of Pneumonia. — It has been found 
that croupous pneumonia is caused by one of four strains 
of pneumococci. To determine which strain is present 
in a given case either the sputum or the fluid withdrawn 
through an aspirating needle, which is plunged into the 
pneumonic consolidation, is injected into a mouse. Six 
hours later a Widal is made with a pure culture of each 
one of the four strains of pneumococci and the blood 
of the mouse. The strain that agglutinates when 



DISEASES OF THE RESPIRATORY TRACT IO9 

mixed with the blood is the type present in that par- 
ticular case. 

Horses have been rendered immune to strains one, 
two, and three, and their serum can be utilized in prac- 
tically the same way as in the antitoxin treatment of 
diphtheria. Strain four is a heterogeneous type and pro- 
duces no reaction in the horse, so there is no serum avail- 
able for this form of the disease; it is the mildest form, 
however, comprising about 30 per cent, of the cases, with 
a mortality of only 6 per cent. 

The effect of the serum is to reduce the temperature 
and to improve the condition of toxemia. It has been 
tried out with very good results at the Rockefeller In- 
stitute in New York. 

Nursing. — The indications are, so far as possible, to 
make the child comfortable during his illness, to prevent 
complications, and to treat the individual symptoms as 
they arise. Bronchopneumonia is frequently a complica- 
tion of one of the infectious fevers, such as measles, 
whooping-cough, and influenza; so in the nursing of these 
conditions prophylactic measures must be employed. 

Perhaps in the majority of cases of pneumonia in child- 
hood hygienic treatment is all that is required. The 
patient should be kept in a large well-ventilated room, 
and, if possible, changed from one room to another two 
or three times a day, to allow thorough airing. Some 
physicians adopt the open-air treatment for pneumonia. 
The child's bed is then placed on the porch or veranda. 
When these do not exist, the bed is drawn in front of an 
open window. The child is protected from the wind, a 
flannel cap and mittens are worn, it is covered with blankets, 
and surrounded with hot-water bottles. 



no DISEASES OF CHILDREN FOR NURSES 

Whenever it is necessary to change any of the clothing or 
to give baths, the child is brought into the warm room. 
The bed is thoroughly warmed with hot-water bottles 
before the patient is again placed in it. Older children 
should be kept in bed; infants can be held in the nurse's 
arms for a considerable part of the time. A frequent 
change of position is essential. The bed-covers should 
never be tucked in tightly. Food should be given at 
regular intervals, and when the child is restless, fretful, 
sleepless, or nervous, sponging with tepid water usually 
makes him comfortable. Severe nervous symptoms re- 
quire the appHcation of ice, either in the form of a cold 
bath or an ice-bag. Pain is usually reheved by the 
application of mustard paste or turpentine stupes. In 
bronchopneumonia an oiled-silk jacket is sometimes 
worn throughout the attack, and, if necessary, counter- 
irritation maintained by mustard paste. Hot poultices 
of flaxseed may be employed. When new poultices are 
appHed the old poultice is first rolled back from one side, 
and the new one is placed in position; then the other side 
is covered in the same way. This prevents exposure. 
Amber oil is also useful. 

Fever in itself means nothing, as it only indicates the 
severity of the lesions. Since a temperature of 105° F. 
is characteristic of pneumonia, it is not necessary to do 
much for it unless it become higher. The nervous symp- 
toms call more often for treatment than the fever, and 
as the two go hand in hand, it is customary to keep 
the fever under control. The best means for this end is 
cold. It may be used by a graduated bath for small 
children, a cold pack for older ones, or a simple sponging 
and an ice-bag. Some physicians use only warm baths 
(100° F.) in their treatment of pneumonia. 



DISEASES OF THE RESPIRATORY TRACT III 

lodin is often applied to the chest in unresolved pneu- 
monia. If the ordinary tincture of iodin causes blistering 
of the skin, it can be diluted one-half with alcohol. 

It is the emergencies which arise in pneumonia with 
which the nurse has to contend. In respiratory failure 
there is great dyspnea, cyanosis, and signs of collapse. 
The physician should be immediately summoned; in the 
meantime, if the child shows great distress in breathing 
while in the recumbent posture, it should be propped up in 
bed, oxygen should be administered; gentle friction of the 
sides of the chest at times stimulates the respiratory mus- 
cles. He may order a mustard tub and hypodermic in- 
jections of one or more of the following drugs: atropin, 
caffein, strychnin, and nitroglycerin. In sudden attacks 
of great cyanosis a mustard tub is advantageous. 

As a moist atmosphere is the best for pneumonia, a 
croup tent with steam atmosphere medicated with com- 
pound tincture of benzoin generally reHeves the dyspnea, 
especially if there is much bronchitis associated with the 
pneumonia. In an ordinary case a child should remain 
in bed for about a week after the normal temperature has 
been reached. 

The temperature, pulse, and respirations should be 
taken every three hours. 



CHAPTER V 

DISEASES OF THE DIGESTIVE TRACT 

The digestive tract is composed of the mouth, tonsils 
and pharynx, the esophagus, stomach and intestines, the 
pancreas, and the Hver. 

The symptoms of the diseases of the digestive tract 
are exhibited in the condition of the tongue, breath, ap- 
petite, and the stools. Vomiting, pain, tenderness, and 
distention of the abdomen are associated symptoms. 

The tongue often has a light, uniform coat in health, 
especially in bottle-fed babies. It becomes heavily coated 
upon the slightest indication of indigestion. The mucous 
membrane covering the tongue is the only part of the 
lining of the ahmentary canal visible, and indicates the 
condition of the mucous membrane in the lower digestive 
tract. The tongue also becomes coated in fever and 
catarrhal conditions of the nose and throat. In several 
diseases there is a characteristic appearance of the tongue. 

In typhoid fever, in the early stages, the tongue is red 
and it often trembles upon extrusion, and later becomes 
dry, brown, and fissured. 

In scarlet fever, in the first stage, the tongue is heavily 
coated with a whitish fur, with the exception of the tip, 
which is red. This whitish fur gradually peels off, so 
that in a day or two the tongue is a deep red, wilh the 
papillae deeply injected. This has given rise to the name 
strawberry tongue, characteristic of this disease. 

112 



DISEASES OF THE DIGESTIVE TRACT II3 

In gastro-enteritis sometimes the tongue is gray-coated 
and flabby, with an oval bare spot in the center, which is 
red and glossy. In older children scars on the tongue are 
due to tooth-wounds inflicted during epileptic convulsions. 




Fig. 31. — Illustrating a very good and common position for mouth and throat examina- 
tion (Kerr). 

Fetor of the hreath is frequently due to some local 
condition, such as chronic rhinitis, tonsillitis; to retained 
particles of food ; to caries of the teeth ; to certain lung dis- 
eases; to dyspepsia; and to the ingestion of certain drugs. 

The condition of the appetite may be inordinate, lost, 
or perverted. The following names have been applied 
to the different varieties of appetite: 



114 DISEASES OF CHILDREN FOR NURSES 

Bulimia is the term applied to an inordinate appetite. 

Anorexia is the term appHed to loss of appetite. 

Pica is a craving for unnatural foods. 

Dysphagia or difficulty in swallowing may result from 
local inflammations, stricture of the esophagus, or paral- 
ysis. 

Malformations. — In infants these are not uncommon. 
The conditions most frequently seen are hare-lip, cleft 




Fig. 32. — Ranula. The growth h"es in the middle of the mouth and seems to be divided 
into two parts by the constriction of the frenum (from Griinwald, Diseases of the Oral 
Cavity). 

palate, and tongue-tie. A large protuberant tongue is 
seen in cretinism. The principal difficulty experienced 
in such malformations is in feeding. The child is unable 
to grasp the nipple and feed properly. Not enough food 
is obtained, and they die from inanition unless the deform- 
ity is corrected. 

Ranula is a cystic tumor of the floor of the mouth due 
to degeneration of the sublingual gland or its excretory 
duct. At times it interferes with swallowing. 



DISEASES OF THE DIGESTIVE TRACT II5 

Feeding in Malformations of the Mouth. — Hare- 
lip. — Here it is impossible for the child to suck. Often, 
if the cleft is held together by the fingers, the child can 
nurse. If this fails, milk is given by means of a medicine 
dropper. 

Cleft Palate. — Here the roof of the mouth is the part 
lacking; this also makes sucking impossible. At times 
will be found useful a special nipple consisting of a broad 
flap of rubber upon the upper surface, which fills the gap 
in the roof of the mouth and thus makes sucking possible. 
Sometimes an inverted bowl of a spoon placed in the cleft 
will answer the same purpose. If these methods fail it is 
necessary to resort to the medicine dropper. 

Tongue-tie. — This condition sometimes prevents proper 
sucking. In the same way the large protuberant tongue 
of cretinism acts as a barrier. The medicine dropper 
may have to be resorted to in these cases. 

If for any reason the medicine dropper is unsuccessful 
in supplying the child with sufficient nourishment, gavage 
may be practised (see page 450). 

Diseases of the Mouth 

Ulcer of frenum is seen in cases of pertussis. It is 
a small ulcer on the frenum caused by the propulsion of 
the tongue against the teeth during coughing. It is easily 
cured by touching with alum. 

Glossitis is the name given to inflammation of the 
tongue. 

Gingivitis is inflammation of the gums. 

Herpes is the ordinary "fever bhster'^ seen so often 
around the lips. It is especially common in croupous 
pneumonia. 



ii6 



DISEASES OE CHILDREN EOR NURSES 



STOMATITIS 

This disease is very common among the poorer class 
of patients. It is due to uncleanHness and to a spongy 
condition of the mouth seen in ill-nourished children. 
There are several varieties named according to the appear- 
ance of the lesions in the mouth. 

Catarrhal Stomatitis. — This is a swelling of the 
mucous membrane of the mouth. The membrane is red 
and injected, the saHva is increased, and either dribbles 




Fig. 33. — Ulcerative stomatitis in a child four years of age: Z, Tooth marks on the 
tongue and mucous membrane of the lips ; g, ulcers (Friihwald and Westcott). 

from the mouth or is swallowed. It hurts the child to 
nurse, and as a consequence food is rejected. There is, 
in addition, restlessness, languor, and some fever. 

Aphthous Stomatitis. — In this condition the mucous 
membrane is swollen and red. There are small, round 
vesicles on the tip of the tongue, on the inner side of the 
lips, and on the cheeks. There may be only a dozen 
vesicles present, or the whole mucous membrane may be 
covered. These Httle vesicles break and leave small, 



DISEASES OF THE DIGESTIVE TRACT 11/ 

shallow ulcers having a red rim. The other symptoms 
of stomatitis common to all varieties are present. They 
are dribbling of saliva, heat and pain in the mouth, re- 
fusal of the child to nurse, restlessness, languor, and fever. 
Ulcerative Stomatitis. — In addition to the general 
symptoms of stomatitis there is an ulceration of the mucous 
membrane beginning at the angle formed at the junction 
of the cheek and the alveolar processes, which is the 
portion of the jaw that holds the roots of the teeth. The 
glands under the jaw are enlarged, but do not suppurate. 




Fig. 34. — Noma of the face (case of A. T. Bazin). 

In severe cases necrosis of the jaw may follow, with a 
subsequent loosening and falling out of the teeth. 

Parasitic Stomatitis (Thrush). — The general symp- 
toms of stomatitis are present. On inspection numerous 
milk-white elevations are found, which on removal leave 
a raw surface. This is due to a fungous growth introduced 
through dirty nipples. 

Gangrenous Stomatitis or Noma. — It is usually seen 



Il8 DISEASES OF CHILDREN FOR NURSES 

in debilitated children between the ages of two and six 
years, and generally follows one of the specific fevers, 
such as measles or whooping-cough. 

The symptoms of stomatitis are marked. The 
cheek, the part affected, is swollen, hard, red, and 
glazed externally; and internally there is noted an 
irregular, sloughing ulcer. There is destruction of the 
tissues and in some cases the skull is exposed. In 
the large majority of cases the end is death. If there is re- 
covery, deformity is present except in a few rare cases 
in which the ulcer does not perforate the skin. 

Prophylaxis. — Always keep the mouth clean in any 
illness, especially in infectious fevers. 

Mercurial stomatitis is caused by the unnatural 
susceptibiHty which certain children have toward mercury. 
It causes soreness of the teeth and redness of the gums. 
If the mercury is continued, necrosis of the jaw sometimes 
results. 

Treatment. — In the treatment of stomatitis the chief 
thing to do is to keep the mouth clean by the frequent 
applications of antiseptic washes. In mercurial stomatitis, 
of course, stop the mercury. Calomel may produce this 
condition in the very susceptible. 

The best mouth wash is boric acid, about lo gr. to the 
ounce. Care should be taken to sterilize thoroughly the 
nipples of the bottles before feeding, and a bottle should 
never be handed from one baby to another. Powdered 
burnt alum applied to ulcers usually causes prompt 
recovery. 

In feeding, the milk should be given cold, by the dropper, 
if necessary. Cool substances relieve the pain and heat 
in the mouth; therefore, cracked ice is acceptable. Fruit 



DISEASES OF THE DIGESTIVE TRACT II9 

and vegetables should be given to older children to counter- 
act the malnutrition, and in children suffering from scurvy 
orange juice should be given frequently. 

In severe cases of stomatitis gavage may be necessary 
(see page 450). 

TONSILLITIS 

Tonsillitis is not common in infancy, but throughout 
childhood it is often seen. It is more common in those 
of a rheumatic tendency and in children who have enlarged 
tonsils. One attack predisposes to others. 

The disease begins from infection of the crypts due 
to the presence of bacteria in the mouth, which excite 
an attack whenever conditions are favorable. 

There are three varieties : simple or catarrhal, follicular, 
phlegmonous, or quinsy. 




Fig. 35. — Chronic follicular tonsillitis (Friihwald and Westcott). 

Symptoms. — In children the constitutional symptoms 
are more prominent than the local. The attack comes 
on suddenly, often with a chill and vomiting. The tem- 
perature rapidly reaches 102° F. to 103° F., and in severe 
forms 104° F. to 105° F., and there is marked prostration. 
The tonsils are swollen and red, and there is some pain 
and difficulty in swallowing. The glands at the angle 



I20 DISEASES OF CHILDREN FOR NURSES 

of the jaw are enlarged, but the swelling is not pro- 
nounced. In the catarrhal form the tonsils are swollen, 
red, and covered with tenacious mucus. 

In the follicular form, sometimes called lacunar angina, 
in addition to the above symptoms there are numerous 
yellowish-white spots on the tonsils. These are due to the 
folhcles or crypts being filled with mucus and exfohated 
epitheHal cells. These can often be pressed out as little 
plugs (see Fig. 35). 

In quinsy, which is comparatively rare in childhood, 
there is an abscess present in the tissues immediately 
surrounding the tonsils. This causes extreme swelHng of 
the tonsils, often so much so that the space between the two 
is almost closed. The local symptoms are more promi- 
nent than the constitutional in this condition. The fever 
is not apt to be over 102° F. and there is not as much 
prostration as in follicular tonsillitis. At the same time 
there is much more pain and difficulty in swallowing. The 
gland affected soon softens, fluctuates, and ruptures. 
It is almost always unilateral in childhood. At its height 
swallowing is almost impossible, the voice is lost, and 
breathing is difficult. 

Treatment. — Pellets of ice and a gargle of chlorate of 
potash, I dr. to a pint of water, give rehef in tonsilhtis, 
and frequently the patient can be rendered more com- 
fortable by the external application of an ice-bag, a poul- 
tice, or iodin over the angle of the jaw. 

CHRONIC HYPERTROPHY OF THE TONSILS 

Repeated attacks of acute tonsillitis lead to a permanent 
enlargement of the tonsillar tissues called hypertrophy. 
The tonsils intrude into the passage leading to the pharynx. 
In severe cases they may almost meet. This causes ob- 



DISEASES OF THE DIGESTIVE TRACT 121 

struction to the passage of food and leads to a chronic 
catarrh of the throat. 

Nearly all cases of enlarged or hypertrophied faucial 
tonsils have associated with them an overgrowth of the 
lymphatic tissue in the pharynx behind the posterior 
openings (nares) of the nose. This is called an adenoid. 
The two conditions together give rise to characteristic 
symptoms. 




Fig. 36. — Diagram (anteroposterior) illustrating by the shaded portion {A) the situation 
of adenoid vegetations in the nasopharynx (Kerr). 

The child sleeps poorly, is restless, and snores. It 
breathes through the mouth and there is constant catarrh 
of the nose and pharynx. From the fact that the catarrh 
can easily extend into the Eustachian tube, which runs 
from the internal ear to the upper part of the pharynx, 
attacks of middle-ear disease {otitis media) are quite 
common, and deafness may result. The child is poorly 
nourished and is subject to acute attacks of tonsillitis. 
It also predisposes to diphtheria and scarlet fever. 



122 



DISEASES OF CHILDREN FOR NURSES 



Treatment. — The best plan is to have the tonsils and 
adenoids removed if the symptoms are sufficiently annoy- 
ing. 

Operation. — According to the size of the tonsils and the 




Fig. 37. — Examination of the nasopharynx for adenoid vegetations. (The examiner in 
this instance is left-handed.) (Kerr.) 

preference of the operator, several methods may be em- 
ployed. The tonsils may be dissected out, removed with 
a snare, cut off by means of an instrument called a guillo- 
tine, or by means of ''biting" forceps. The pharyngeal 
tonsils or adenoids are removed at the same time. The 



DISEASES OF THE DIGESTIVE TRACT 1 23 

operation is without danger. The complete removal of 
the faucial tonsils by dissection seems to be the best 
method. The secondary hemorrhage can be controlled 
by pellets of ice, pressure, or cotton containing some 
styptic, like Monsel's solution. It is usually a per- 
manent cure. 




Fig. 38. — Typical appearance in adenoid vegetations: Boy ten years old (Friihwald 

and Westcott). 

The nasopharynx is usually irrigated with normal salt 
solution after the operation, and cold things to eat, like 
ice-cream, are most acceptable. 

PSEUDODIPHTHERIA OR VINCENT^S ANGINA 
This is the name given to an ulceromembranous form of 
inflammation which attacks the mucous membrane of the 



124 DISEASES OF CHILDREN FOR NURSES 

mouth and tonsils. It is characterized by the formation 
of a membrane, yellowish-gray in appearance, and very 
offensive. When this membrane is stripped off it leaves 
a raw, bleeding surface behind. In twenty-four or forty- 
eight hours a deep, punched-out ulcer forms, with injected 
edges. The constitutional symptoms are mild. The tem- 
perature ranges between ioo° F. and 102° F. In three 
or four days the ulcer gradually heals. 

Differential Diagnosis. — The appearance of this con- 
dition is very similar to diphtheria, especially when the 
fauces and tonsils are the seats of the inflammation. The 
bleeding which accompanies the stripping of the membrane 
is very misleading. The differential diagnosis can be de- 
termined only by an examination, under the microscope, 
of a smear, properly stained, taken from the lesion. The 
Klebs-Loffler bacillus is not present, but two characteristic 
bacilli are found. They are called spirillum and fusiform, 
from their shape. The disease is only mildly contagious, 
if at all. 

The necessity of making an absolute diagnosis, by means 
of microscopic examination, between Vincent's angina and 
true diphtheria is of the greatest importance. True 
diphtheria is subject to quarantine; Vincent's angina is 
not; diphtheria is a very grave disease; Vincent's angina 
usually is mild, although in severe cases noma and sep- 
ticemia may develop. Finally,, in diphtheria others 
should immediately receive antitoxin, as well as the patient. 
This is Dot necessary in Vincent's angina. 

PHARYNGITIS 

Pharyngitis is an acute sore throat, or, more particu- 
larly, an acute inflammation of the' mucous membrane 



DISEASES OF THE DIGESTIVE TRACT 1 25 

lining the pharynx. In childhood most of the contagious 
diseases, such as measles, scarlet fever, etc., are accom- 
panied by a secondary pharyngitis. 

Symptoms. — The disease is ushered in suddenly by 
profuse redness of the mucous membrane of the pharynx 
and a temperature which may reach 103° F. to 104° F. 
in a child. The whole vault of the pharynx, uvula, and 
fauces, may be involved. The inflammation pursues the 
same course as an inflammation of the mucous membrane 
anywhere. There is congestion, swelling, dryness, fol- 
lowed by an oversecretion of mucus, which soon becomes 
mucopurulent. The surrounding lymph-glands may be 
slightly enlarged. There is pain at the angle of the jaw 
and upon swallowing, a hacking cough, and stiffness and 
tenderness of the muscles of the neck. Extension to the 
larynx may cause hoarseness; to the ear, deafness (through 
the Eustachian tube). An inspection of the throat reveals 
a red and swollen mucous membrane. Simple, rheumatic, 
follicular, and infectious varieties are found. The first 
three explain themselves and the last is associated with 
the infectious fevers. 

Treatment. — The local treatment is the same as in 
tonsillitis, with the addition of a steam spray medicated 
with compound tincture of benzoin, which frequently 
gives added relief. Pellets of ice may be used to good 
advantage. 

All cases of acute sore throat should be looked upon 
with suspicion, as in most contagious diseases it is the 
first symptom. This is especially true of measles and 
diphtheria. If either of these diseases is prevalent, 
the case should be isolated until the time for the appear- 



126 DISEASES OF CHILDREN FOR NURSES 

ance of the rash has past or the culture from throat is 
found to be negative. 

Uvulitis is an inflammation of the uvula or soft palate 
associated with pharyngitis. At times an elongation of the 
uvula renders it necessary to remove a small portion. 

Chronic pharyngitis is not common in childhood.^ It 
usually results from repeated acute attacks and the 
improper use of the voice. 

Symptoms. — The voice is husky and there is an in- 
creased secretion, so that there is a constant desire to clear 
the throat. Disagreeable sensations, such as fulness, tick- 
ling, and the like are frequently noted. 

Four forms are found: the hypertrophic pharyngitis in 
which the membrane has become permanently thickened 
and causes a constant clearing of the throat. 

An atrophic pharyngitis, in which the menxbrane is 
thinned out and secretion is lacking. 

Ulcerative pharyngitis, in which the membrane is 
covered with ulcers due to simple inflammation, or the 
ulcers of syphilis or tuberculosis. 

Phlegmonous pharyjtgitis, or retropharyngeal abscess, 
is due to a suppuration of the tissues behind the pharynx 
caused by caries of the cervical vertebra:^, the impaction of 
a foreign body, or as a sequel to one of the infectious 
fevers. 

The cases which arise independent of the above causes 
must be considered (Holt) as a retropharyngeal adenitis 
(inflammation of the lymph-glands). This may advance 
to the stage of suppuration, as it does in the majority of 
cases, when pus is present, or in very rare cases the in- 
flammation may cease before this stage is reached. 



DISEASES OF THE DIGESTIVE TRACT 12/ 

Children under one year of age are those most often 
attacked. It is rarely seen over five years of age. 

The symptoms are as follows- At first the child may 
have severe nasal pharyngeal symptoms, accompanied by 
fever. These symptoms subside, but the fever still remains 
above normal. Several days later the temperature again 
rises to 103° F. and the local and pressure-symptoms 
appear. 

In other cases the onset is sudden and the local and 
pressure-symptoms are the first to manifest themselves. 

The characteristic symptoms are due to pressure and 
are dyspnea from partial closure of the opening of the 
larynx, difficulty in swallowing from obstruction to the 
passage of food, mouth-breathing from the closure of the 
posterior nares, which gives rise to the characteristic 
''quack." The head is thrown back to elevate the mass 
and relieve the pressure. There are profound constitu- 
tional symptoms, the child appears desperately ill, and 
the appearance of the pharjnix on inspection is characteris- 
tic. There is a bulging of one of the sides of the pharynx, 
the amount of protrusion varies. In some cases the uvula 
is pushed to one side and the pharynx filled up. The 
severity of the symptoms due to pressure depends upon 
the size of the protruding mass. The tumor soon fluc- 
tuates, showing the formation of pus, and the temperature 
becomes hectic (due to pus; high, irregular temperature, 
accompanied by chills, sweats, and pallor). If left to 
itself the abscess will rupture, usually in two or three 
days. Sometimes it is delayed for a week or two. 

As soon as the fluctuation is discovered the abscess 
should be incised with a guarded bistoury. This is done 
so that the pus can be controlled. If allowed to rupture 



128 DISEASES OF CHILDREN FOR NURSES 

itself the pus may be swallowed or inspired. This may 
cause grave complications, such as aspiration pneumonia 
or asphyxia. The child should be firmly held in the 
nurse's lap, with head thrown back. A tongue depressor 
is used by the physician, as it can be immediately 
withdrawn, and not a mouth-gag. As soon as the 
abscess is opened the nurse should bend the child's 
head forward and thus allow the pus to run out of 
the mouth. 

Some surgeons prefer to have the child lie on a table 
with head hanging backward over the end. After the 
abscess is lanced the head should be turned to one side 
to allow pus to escape. The after-treatment is simple, 
as the symptoms disappear as soon as the pus is 
removed. 

Retropharyngeal abscess from PoWs disease is due to 
the softening of the cervical vertebra^ with accumulation 
of pus behind the pharynx. It is slow in forming and not 
attended by much fever. Such abscesses are opened 
externally when the pressure-symptoms become of suf- 
ficient importance to demand relief. 



CHAPTER VI 
DISEASES OF THE DIGESTIVE TRACT 

(Continued) 

Diseases of the Esophagus 

The esophagus is rarely involved in inflammatory 
processes. The only condition of importance to a nurse 
is corrosive esophagi tis and stricture. 

Corrosion of the Esophagus. — This is almost always 
due to the swallowing of strong acids or alkalies. It causes 
intense pain and burning in the esophagus and swallowing 
is very painful. 

Stricture is a secondary result of corrosion. The 
healing ulcer causes a narrowing of the alimentary canal 
at its location, and this interferes with swallowing. 

Symptoms. — A slowly increasing difficulty in deglutition, 
with regurgitation of food. The esophagus is often much 
dilated above the stricture, and the food may collect in 
the pouch thus formed, so that regurgitation may be 
delayed for several hours. There is much loss of flesh. 
In bad cases of stricture it is necessary to place the 
child upon a liquid diet. 

Diseases of the Stomach 
In infancy we rarely find the stomach involved alone, 

being associated with the intestines in nearly all diseases. 

In older children the stomach conditions may be distinct. 

Capacity. — At birth the capacity of the stomach is 

about i\ ounce. 

129 



130 DISEASES OF CHILDREN FOR NURSES 

For all practical purposes it is safe to say that the 
capacity of.the stomach increases about i ounce for each 
month, up to eight months; then its development is slower. 
At one year the capacity is 9 ounces; at eighteen months 
12 ounces. 

As the quantity of food taken at feeding increases, the 
time it takes the stomach to empty itself lengthens. From 
two to eight months of age it takes about two hours for 
mother's milk and two and a half hours for cows' 
milk. 




Fig. 39. — Stomach of infant at birth, natural size (J. P. C. Griffith). 

The position at birth is peculiar in that it is almost 
vertical instead of being horizontal. This explains the 
ease with which newly born babes regurgitate. There is 
no attending discomfort, being hke the running over of 
a filled bottle. 

Digestion of Milk. — Mother's milk is coagulated into 
light, flocculent curds. Cows' milk is coagulated into 
tough, compact masses, and it takes about a half hour 



DISEASES OF THE DIGESTIVE TRACT 



131 



longer for the stomach to empty itself of this diet than it 
does of mother's milk. 

Vomiting is a condition arising from a large number 
of sources. It may be watery or mucous; bihous or green, 
which occurs in any case where i^omiting and straining are 
continued; bloody (hematemesis); or purulent, resuking 
from the rupture of an abscess into the stomach or esophagus. 




Fig. 40- — The abdominal regions. The heavy line at the upper border shows 
the extreme limit of the diaphragm. Imaginary lines divide the abdomen into different 
regions which, for the sake of clearness and precision, are known as the right and left 
hypochondriac, the epigastric, the right and left lumbar, the umbilical, the right and 
left inguinal or iliac, the hypogastric (Kerr). 



Fecal vomit {stercoraceous) is indicative of intestinal 
obstruction and is recognized by its odor and appearance. 

Profuse vomiting, where large quantities of frothy, 
fermented material are ejected, is significant of gastric 
dilatation. 

Vomiting without nausea, distress, or other gastric 



132 DISEASES OF- CHILDREN FOR NURSES 

symptoms occurs in certain neuroses of the stomach, in 
hysteria, uremia, and in brain diseases, such as tumor or 
meningitis. This form of vomiting is seen at the onset 
of many fevers in childhood. 

Habit vomiting is the name given to that form of emesis 
in which children vomit from habit alone, no disease of 
the stomach being present. 

Cyclic vomiting is characterized by severe attacks of 
vomiting occurring at more or less regular intervals. It 
is uncommon and is of nervous origin. 

Hematemesis is the term applied to vomiting of blood. 
If the hemorrhage is rapid and the blood immediately 
vomited, it may be bright red in color. However, it is 
usually retained for some time in the stomach before 
ejection, and is then dark brown in color, the so-called 
coffee-ground appearance. The blood is mixed with food 
and the subsequent stools are dark and tarry. 

Hiccough or singultus results from a clonic spasm of 
the diaphragm. It is often noted as a temporary condition 
after eating and drinking. Persistent hiccough is fre- 
quently present in cases of extreme exhaustion following 
acute or chronic diseases. 

Malformations and Malpositions of the Stomach. — 
The cardiac and pyloric ends may be congenitally stenosed 
(no opening). At times the stomach is found in the 
thorax, gaining access through a rupture of the diaphragm. 

Pyloro spasm is the name given to a serious condition 
of early infancy, in which there is a spasmodic affection 
of the pylorus, with an overgrowth of the circular mus- 
cular fibers at this point, which produces an obstruction 
at the outlet of the stomach. 

It is analogous to the other spasmodic conditions of 
early infancy, such as constipation due to spasm of the 



DISEASES OF THE DIGESTIVE TRACT 1 33 

sphincter ani; intussusception due to irregular or inter- 
mittent muscular spasm of the intestines, and the spas- 
modic affections of the larynx and bronchi. 

The symptoms begin almost always during the first 
month. There is occasional vomiting, which soon be- 
comes habitual, it is very forcible in character; constipa- 
tion develops, and the child loses weight very rapidly, 
amounting to i or 2 ounces a day. There is no fever, no 
pain, and no signs of indigestion. There is marked 
visible gastric peristalsis seen when the stomach is full; 
it is a slow wave moving from left to right every minute 
or two. The stomach becomes dilated, and a hard car- 
tilaginous tumor about the size of a peanut can be felt 
during peristalsis at the pylorus, due to the hypertrophy 
of the circular muscular fibers. There is no bile in the 
vomit and the stools look like meconium. 

Fifty per cent, of the cases end fatally in from four to 
six weeks. 

Treatment. — The medicinal management of pyloro- 
spasm consists in stomach washing and the employment 
of proper dietetic methods, consequently a skilful nurse 
is invaluable. Operation is avoided if possible and is 
considered only as a final resort. 

Diet, — The feedings should not be too near together 
and small amounts should be given. Breast feedings 
should be at three-hour intervals and the nursing period 
from three to eight minutes, according to the amount 
obtained. A good method is to pump the breast, giving 
definite amounts, such as 2 ounces at a feeding at one 
month. The children should not be weaned and arti- 
ficially fed children often do well with a wet nurse. 
Where this is impracticable, the fat should be low in the 



134 DISEASES OF CHILDREN FOR NURSES 

milk formulas; skimmed milk succeeds. The necessary fat 
can be supplied by olive oil when the fat of milk causes 
extra vomiting. Egg-albumin and beef-juice are good. 

Lavage empties the stomach of food and mucus and al- 
lays the spasm. It should be done two and a half hours 
after feeding and repeated twice in twenty-four hours. 
It should be continued for six or eight weeks and once 
daily for three or four months in the cases that recover. 

The water should be from io8° to iio"^ F., rendered 
alkaline by i per cent, of sodium bicarbonate. A meas- 
ured quantity of water should be used, which should be 
remeasured when washing is complete, the extra amount 
obtained will determine the amount of retained food that 
was in the stomach. 

Weight. — ^A careful weight chart should be kept, for 
when there is a slow gain the tide has turned. 

Operation. — This is a gastro-enterostomy (an arti- 
ficial opening from the stomach into the intestines, thus 
avoiding the necessity of the food passing through the 
pyloric valve). 

After operation the Murphy method of continuous 
induction of water into the intestines will probably be 
employed. (See page 45 1-) 

Vomiting may be allayed by placing the child in a semi- 
erect position. 

Feeding should be followed by long periods of rest. 

ACUTE GASTRIC INDIGESTION 

Acute gastric indigestion is the name appHed to a series 
of symptoms caused by the inability of the stomach to 
properly digest. 

The symptoms are vomiting, dulness, or excitement, 



DISEASES OF THE DIGESTIVE TRACT 1 35 

and at times convulsions. The temperature ranges from 
100° F. to 102° F., sometimes higher. The tongue is 
coated, the appetite lost, and the abdomen distended. 
In infants there is an associated diarrhea, the stools con- 
taining undigested food. From six to twelve hours after 
the onset the vomiting ceases and the symptoms disappear. 

GASTRITIS 

Acute Gastritis is an acute inflammation of the stomach. 
The mucous membrane is red, sticky, and lusterless; it is 
swollen and covered with thick mucus. 

Symptoms. — They vary much in degree. In severe 
cases there is moderate fever (102° F. to 103° F.) and its 
associated phenomena. There is loss of appetite, a 
coated tongue, and intense pain in the epigastric region, 
which is tender to the touch. In addition there is per- 
sistent vomiting, thirst, and considerable prostration. 
Jaundice may follow from the extension of the catarrh to 
the bile-ducts, and diarrhea from extension to the intes- 
tines (gastroduodenitis) . 

The treatment is absolute rest. If the stomach is not 
entirely empty an emetic should be employed. To re- 
lieve the pain in the stomach local applications such as 
turpentine stupes or a mustard plaster will be found 
effective. In severe cases no food should be given by the 
mouth. To allay * the thirst cracked ice may be given, 
and later milk and lime-water. 

Chronic Gastritis (Chronic Gastric Indigestion, 
Dyspepsia). — This is a chronic indigestion and signifies 
a group of symptoms which accompany every disease of 
the stomach. When, however, the symptoms depend 
upon nothing more than simple atony, hypersensitiveness, 



136 DISEASES OF CHILDREN FOR NURSES 

or chronic catarrh, the condition is spoken of as a distinct 
affection. Corresponding to this view there are three 
forms recognized: (i) Atonic, (2) nervous, (3) catarrhal. 

In infancy chronic gastritis is due to the abundant, 
tough, adherent mucus hning the stomach. This inter- 
feres with digestion, even though the stomach secretions 
are normal. 

The symptoms are : long retention of food, vomiting six 
to eight hours after eating, signs of general malnutrition, 
and undigested food in stools. There is also dilatation 
of the stomach. In infants under three months the 
prognosis is bad. 

In older children chronic gastritis is usually caused by 
gastric irritants such as tea and coffee in excess, by dietetic 
errors such as insufficient mastication from bad teeth, 
hurried eating, too much food, insufficient food, coarse or 
improperly cooked food, excessive dilution of food with 
liquids, excessive condiments, and irregular eating. 

Symptoms of chronic gastritis are: coated tongue, per- 
verted appetite, distress after eating, eructations, flatulence, 
heart-burn, palpitation, headache, vertigo, disturbed sleep, 
and lassitude. 

In atonic dyspepsia the above symptoms are present 
and the pain usually appears some time after eating. 

In nervous dyspepsia the above symptoms appear in 
nervous children. The symptoms vary greatly. At one 
time there will be anorexia, at another an inordinate 
appetite, and at still another a perverted taste. Pain and 
vomiting or retching occur just as frequently when the 
stomach is empty as when it is full. 

In catarrhal dyspepsia a condition of chronic inflamma- 
tion of the stomach exists. Just as in a chronic inflamma- 



DISEASES OF THE DIGESTIVE TRACT 1 37 

tion of the mucous membrane in any other part of the 
body, so here there is a thickening of the membrane and 
the process of digestion is interfered with. The food 
remains for a long time in the stomach and undergoes 
fermentation; thus eructations of gas and sour Hquids 
are frequent. There is more or less nausea, with vomiting, 
at all times, but especially so in the morning when the 
frothy mucus, which has collected over the mucous mem- 
brane during the night, is vomited together with much 
retained, fermented food. 

In catarrhal dyspepsia the nurse is often instructed 
to wash the patient's stomach every morning by lavage 
(see page 448). 

GASTRALGIA 

Gastralgia is a painful, paroxysmal (intermittent) affec- 
tion of the stomach not associated with any organic lesion. 

Symptoms. — There are paroxysms of severe pain in the 
epigastrium, usually radiating to the back and occurring 
when the stomach is empty. It is relieved by pressure 
and the ingestion of foods or warm, stimulating drinks. 

Treatment. — The child should be put to bed and hot 
water or turpentine stupes appHed to the epigastrium. 
If the feet are cold apply hot-water bags there. Hot 
water containing five or ten drops of brandy and five drops 
of turpentine should be sipped. 

GASTRIC ULCER 

This is a rare condition in childhood. Ulcers may 
result from folHcular gastritis, tuberculosis, or without 
obvious exciting cause. The latter is probably due to 
the digestion of a portion of the stomach by its own juices. 
This occurs when some local disturbance of the circulation 



138 DISEASES OF CHILDREN FOR NURSES 

shuts off the blood-supply to a portion of the stomach 
walls, the lowered vitaHty of that portion permitting the 
gastric juice to digest it. This produces the ulcer. 

A gastric ulcer is round or oval and is usually situated at 
the pylorus on the posterior wall, near the lesser curvature. 
It is a punched-out ulcer, the apex toward the peritoneum, 
while the floor is usually formed by one of the coats of the 
stomach. A series of ulcers is not uncommon. 

S)rmptoms. — The general symptoms of dyspepsia are 
present, and in addition the following characteristic 
symptoms: Pain, which may be severe, appears soon after 
eating and almost always radiates toward the back. Hem- 
orrhage is present in one-half of all cases. The bleeding 
may be profuse and the blood bright red. Localized 
tenderness, nearly always two or three inches above the 
umbiHcus. Vomiting, occurring an hour or two after eat- 
ing and at the height of the pain. Hyperacidity, which is 
an increase in the hydrochloric acid after a test-meal. 

This is a dangerous affection, demanding absolute rest 
in bed and rectal feeding. 

DILATATION OF THE STOMACH 

Moderate dilatation is often seen, a very marked 
dilatation is rare. 

Causes. — Rickets, chronic gastritis, and pyloric stenosis. 

The only symptoms present in most cases are those of 
chronic gastric indigestion. 

In stenosis of the pylorus tl^ere is added vomiting of 
large quantities of fermented food, which occurs after the 
lapse of several hours. 

In some cases of gastric dilatation the stomach is washed 
daily (see Lavage, page 448). 



DISEASES OF THE DIGESTIVE TRACT 1 39 

Gastroptosis and enteroptosis is a prolapse or down- 
ward displacement of the stomach and intestines. 

TEST-MEALS 

The ordinary test-meal consists of a dry roll and two- 
thirds of a pint of water or weak tea, without milk or sugar. 

In testing for lactic acid the test-meal should consist of 
a tablespoonful of oatmeal to a Hter of water, flavored 
with a small quantity of salt. 

Method of Administration. — The child should be 
given a very light breakfast. Four hours later the stomach- 
tube should be introduced and the stomach washed (see 
Lavage, page 448). The meal should then be eaten, 
and in an hour recovered by means of the stomach-tube. 
About 40 c. c. should be obtained. 

NURSING 

In diseases of the upper gastro-intestinal tract the 
room should be light and sunshiny, well ventilated, and 
kept at an even temperature. 

The clothing should never bind the abdomen. 

Bathing may be continued, except in the more severe 
forms of illness and in sore throat. 

The food should be carefully prepared and given 
absolutely according to instructions. At times in severe 
vomiting it is necessary to prohibit food by the mouth. 
Nothing should then be allowed to enter the stomach. 

The character of the vomit must be noted ; the length of 
time after eating it occurs is important; and the presence 
of blood should be immediately reported. 

Unless there is fever the temperature, pulse, and respira- 
tions need be taken but once or twice a day. 



CHAPTER VII 
DISEASES OF THE DIGESTIVE TRACT 

(Continued) 

Diseases of the Intestines 

The small intestine at birth is about 9 feet long, and 
the large intestine about 18 inches long. The lower 
half of this length is occupied by the sigmoid flexure. 

Feces. — The first stools after birth are called meconium. 
Four to six stools a day of this discharge are natural. By 
the fifth day the stools should assume the appearance of 
milk feces. 

Milk Feces. — The normal amount discharged by a 
healthy nursing infant is 2 or 3 ounces. They are soft, 
yellow, and of good consistency. 

Mother's milk and cows' milk give practically the same 
stool. The number of stools during the first two weeks is 
from three to six daily. After the first month two stools 
a day is the average. 

Symptoms. — The chief symptoms of any disease of the 
intestines are constipation, diarrhea, and tormina. When 
the rectum is the seat of the lesion we have added tenesmus. 

Constipation is an unnatural retention of fecal matter. 
Its symptoms are infrequent stools, dyspepsia, fetid breath, 
headache, vertigo, lassitude, and anemia. In aggravated 
cases we frequently find hemorrhoids, fissures, fistulae, 
and prolapse of the rectum accompanying these symptoms. 

In infancy ordinary constipation nearly always can be 
corrected by the proper milk mixture, increase in the fats 
140 



DISEASES OF THE DIGESTIVE TRACT I41 

being all that is necessary. A soap-stick, some form of 
suppository, or introduction of the greased little finger 
act well in stubborn cases. At times enemas are neces- 
sary. These should not be used continuously. 

In older children ordinary constipation can usually be 
overcome by a regular time for defecation and systematic 
exercise; abdominal massage and electricity are valuable 
aids. Encourage the use of water, bran-bread, green 
vegetables, and stewed fruit. A glass of water before 
breakfast is often all that is required. 

Chronic Constipation. — As long as the child has the 
proper strength food for its age, constipation should not 
be troublesome. In artificially fed children, however, 
cases of chronic constipation are quite frequent. The 
nurse can correct this fault to a great extent by proper 
management of the case. 

In older children the most important measure is to 
estabhsh a regular time for stool. After breakfast is the 
best hour. The diet should be mixed, starchy food re- 
stricted, and fruits encouraged. Meat and green vege- 
tables should be eaten at least once a day, oatmeal is the 
best cereal, and orange-juice and stewed prunes the best 
fruit. Massage should be practised twice a day, after 
retiring and in the morning. The proper method of giving 
massage is to use only the hand (without grease of any 
kind), rubbing the abdomen with a circular motion. The 
object is to move the skin and muscles upon the intestines, 
which starts peristalsis, the worm-like movements that 
force the feces along. Exercise is accompHshed during 
playtime, and is usually sufficient. Suppositories are 
valuable at times to start the habit of defecation at a 
regular hour, but should not be continued longer than 



142 DISEASES OF CHILDREN FOR NURSES 

absolutely necessary. Gluten and glycerin suppositories 
are the best. If injections are necessary, i dr. of glycerin 
to J ounce of water gives the most immediate results. 
At stool a low chair aids the child better than the high seat 
for adults. 

Diarrhea is a condition in which the stools are either 
too frequent or too loose. Like -dyspepsia, it is a symptom 
of many pathologic conditions. Any condition which 
tends to lessen the peristalsis of the bowel will cause 
constipation; any condition which tends to irritate the 
mucous membrane of the bowel will usually cause diar- 
rhea. 

Tormina or intestinal colic is a painful, spasmodic 
affection of the intestines. It is generally the result of 
irritating food, flatulence, or fecal accumulation. It is 
characterized by paroxysms of severe pain of a twisting 
character centering around the umbiHcus and relieved 
by pressure. The abdomen is usually distended. Severe 
attacks may lead to incipient collapse, indicated by cold 
sweats, pinched features, feeble pulse, and vomiting. 
The attacks often last from a few minutes to several hours, 
and generally end by a discharge of flatus. In severe 
attacks enemas, hot applications, aromatic spirits of 
ammonia, and paregoric are necessary. 

Tenesmus is a feeUng of fulness in the rectum with a 
constant desire to defecate. 

MALFORMATIONS 

Congenital atresia of the anus is seen occasionally. It 
should always be looked for after birth. Through some 
fault of nature in these cases the rectum becomes con- 
stricted, or the skin covers its outlet. This prevents any 



DISEASES OF THE DIGESTIVE TRACT 1 43 

fecal passage. It results in death if prompt relief is not 

obtained. 

A baby that does not have a bowel movement in the 

first twenty-four or forty-eight hours should be examined 

immediately. 

DIARRHEA 

Diarrhea is an acute inflammation of the mucous mem- 
brane lining the intestines. It is the so-called intestinal 
catarrh. The different varieties of acute diarrhea are: 
mechanical^ caused by foods which act as foreign bodies; 
drug^ caused by any of the ordinary cathartics in suscep- 
tible children ; acute intestinal indigestion; nervous diarrhea; 
and diarrhea of certain diseases like uremia. 

The character of the diarrhea depends upon the seat of 
the lesion. Inflammation high up in the bowel causes 
yellow and greenish stools; in the lower bowel more mucus 
and blood are found and less of the undigested food ele- 
ments. The lower in the bowel the seat of the inflamma- 
tion is, the more severe the symptoms become; the tem- 
perature is higher, the prostration greater, and the stools 
are mixed with blood. When the lower colon and rectum 
are involved, in addition, there is tenesmus, which is a 
sensation of fulness of the rectum, with a constant desire 
to defecate. 

Acute Intestinal Indigestion. — In young children an 
acute attack of indigestion shows both gastric and intes- 
tinal symptoms; the intestinal symptoms, however, are 
always the more marked of the two. In older children 
intestinal indigestion alone is seen. 

The symptoms are coKcky pain, distention, and diarrhea. 

The pain is locahzed in the stomach and around the 
umbilicus. About an hour or two after the onset of the 



144 DISEASES OF CHILDREN FOR NURSES 

attack diarrhea develops. From four to twelve stools are 
passed. They are greenish-yellow in infants, and contain 
undigested food. There is fever, ioo° F. to 102° F. 
The pulse is rapid and the features pale and pinched. 

Treatment. — Give castor oil and restrict the diet. In 
nursing babies give barley-water for twenty-four hours, 
and at the end of this time return to the breast. The 
feedings should be at six-hour intervals and the baby 
allowed to remain at the breast only for five minutes at a 
feeding. Barley-water is given in the interval. The diet 
of older children in the acute stage should be similar to 
that of an infant. Later, broths, eggs, milk, and dried 
bread or toast can be given. Fruit, vegetables, and 
cereals should be withheld for several days and then re- 
turned to slowly. 

Chronic Intestinal Indigestion. — In infants the symp- 
toms at times resemble marasmus. The symptoms most 
often seen are loss in weight, anemia, colicky pain, alter- 
nating diarrhea and constipation. The bowel movements 
are characteristic. If there is diarrhea the stools are 
greenish and often contain white curds. If constipated, 
the stools are often white. The child cries a great deal, 
is very restless, and sleeps poorly. 

Treatment. — It is in these cases that the proper modifica- 
tion of milk does so much good. In very stubborn cases 
buttermilk, properly prepared, seems to cure. 

The proper way to prepare buttermilk is as follows: 
Flour, 3f dr.; cane sugar, 15 dr.; buttermilk, i quart. 
Bring up to the boiHng-point, stirring continuously. Then 
cool rapidly. While the percentage of proteids in this 
mixture is much higher than is usually given in such 
conditions, it is more easily and rapidly digested. Often 



DISEASES OF THE DIGESTIVE TRACT I45 

the improvement is remarkable. Buttermilk should not be 
used for any length of time without the addition of cream. 

In older children^ from four to seven years of age, the 
symptoms are as follows: The child is under-developed, 
pale, thin, and has a prominent abdomen. There are 
dark rings under the eyes, they easily tire, and are fretful 
and emotionalo The stools are foul, there may be con- 
stipation or diarrhea, and a great deal of gas. Such 
children frequently grind their teeth, giving rise to the 
supposition that they have worms. Convulsions are not 
uncommon. 

Treatment. — In such cases a trained nurse is invaluable. 
The chief thing to regulate is the diet. This should be 
placed entirely in her hands. It is a fact th'^t the princi- 
pal diet of children suffering with this condition usually 
consists of sugar, potatoes, and oatmeal. These should 
be interdicted, and for a beginning a diet of rare meat 
(scraped beefsteak or mutton), and milk instituted. 
Under the physician's orders, additions will be made, 
consisting of fruit, kumiss, stale bread, raw oysters, 
vegetables, etc. Potatoes and oatmeal should be for- 
bidden for some time in these cases. Proper clothing, 
cold sponging in the morning, open-air exercise, and cool 
sleeping-rooms are of equal importance. 

Summer Diarrhea. — -When diarrhea attacks young 
children in the summer time, it is the so-called summer 
diarrhea of childhood. This is the most fatal disease of 
childhood. It occurs in epidemic form regularly every 
summer in most large cities. The changes in the bowel 
are slight, amounting in most cases only to a superficial 
catarrhal inflammation, often bearing no relation to the 
severity of the symptoms. These are mainly due to the 



146 DISEASES OF CHILDREN FOR NURSES 

absorption of toxic materials resulting from putrefactive 
changes in the stomach and intestines (Holt) . 

The chief cause of summer diarrhea is bad milk. The 
term "milk infection" is frequently used by physicians in 
defining this condition. 

Milk which has been delivered to the consumer under 
the most favorable conditions will show a number of bac- 
teria on examination^ 

When proper aseptic precautions are taken at a dairy, 
the herd is proved to be physically sound, the stables are 
clean and hygienic, the cattle's food is scientifically super- 
vised, the milk cans and the clothing of the dairymen are 
sterilized, their hands and the udders of the cows are 
thoroughly cleansed, the milk is immediately placed in 
sealed glass quart bottles, packed in ice, and delivered as 
quickly as possible, still from two to ten thousand 
bacteria per cubic centimeter will be present. One can 
imagine the number of bacteria in a cubic centimeter 
of the ordinary milk which is delivered by the itinerant 
milk man. A hundred thousand per cubic centimeter 
is common in the summer time, and in samples of bad milk 
over a million have been found. 

The Philadelphia Pediatric Society, which has the super- 
vision of issuing certified milk certificates in this vicinity, 
has made ten thousand bacteria to the cubic centimeter 
the limit for certified milk. As there are only about a half 
dozen dairies which can comply with this standard in an 
area which comprises about 2,000,000 people, one can see 
the difficulty in obtaining good milk. 

When impure milk is given to an infant the toxins 
generated in its digestive tract produces the symptoms so 
characteristic of this condition. 



DISEASES OF THE DIGESTIVE TRACT 1 47 

The symptoms of the milder form are frequent stools, 
three to twelve a day. They are of yellowish or greenish 
color and contain undigested food. They are colicky pains 
with rumbling noises (borborygmi), and slight fever with 
its attending phenomena These symptoms usually follow 
an acute attack of indigestion and are accompanied by 
gastric symptoms which may set in at almost any time after 
its onset, the principal feature of which is the persistent 
vomiting. After a time the stools become offensive, 
mucus is present, the appetite may be normal, but is often 
impaired and may be almost lost. The tongue is coated, 
the, mucous membrane of the mouth is congested, and in 
very young infants is often covered with thrush. The 
general health may not be noticeably affected for several 
days, but more often the infants become pale, their Hmbs 
grow soft and flabby, they lose their spirits, are fretful, 
sleep badly, and the scales show a decrease in weight of 
from one to two pounds a week. Relapses are common, 
especially if the infants are placed upon a milk diet too soon, 
or by overfeeding. 

In the more severe form the attack may begin abruptly, 
or there may have been symptoms of the milder variety 
for several days. The temperature rises rapidly to 103° F., 
often to 105° F. There is great thirst. The children are 
restless, excited, and may have convulsions, or they may be 
just the opposite, and lie in a dull stupor. From four to six 
hours after the onset, vomiting begins, milk appearing as 
tough curds and very som:. After the stomach is emptied 
retching continues, and everything given by the mouth is 
almost immediately rejected. Diarrhea follows. The 
stools are thin, yellowish, greenish, brownish, or mixed, 
very offensive, and frequently accompanied by the discharge 



148 DISEASES OF CHILDREN FOR NURSES 

of large quantities of gas with accompanying colicky pains. 
In fact, the foul odor, the colic, and the discharge of flatus 
is the most characteristic symptom of this form of diarrhea. 
From five to twenty-five fluid stools in twenty-four hours, 
frequently of good size, and very offensive, are seen after the 
first day. In a few days mucus may appear. After two 
or three days there is generally a reaction and the child 
improves. The stools, however, may continue loose for 
five or six days, gradually assuming their normal character. 

If there is no reaction, steadily increasing prostration, 
continued high temperature, and diarrhea may cause a 
fatal termination of the case. 

In other cases the symptoms merge into those of entero- 
colitis. At times there may be a series of acute attacks a 
week or ten days apart; in the interval all symptoms are 
absent except that the stools never become normal. The 
third or fourth such attack may merge into enterocolitis. 

Prophylaxis. — ^As this disease is caused by impure milk, 
all that is said about the care of the milk in the house and 
the sterilization of bottles and nipples on page 399 should 
be carefully read. It is frequently necessary for all milk 
to be pasteurized during the summer months (see page 

363)- 

During the hot months the infant's clothing should 
be light flannel; a single-piece dress is the best. Their 
napkins should be changed immediately after soiling. 
They should have fresh air, sunlight, and frequent bath- 
ings. Maternal nursing should be practised in every case 
where it is possible. Weaning should be avoided during 
the summer months. Overfeeding should be prohibited. 
Less food at a feeding by one-third, and more water, is 
a good rule to follow during the hot weather. Early 



DISEASES OF THE DIGESTIVE TRACT 1 49 

attention should be given to all mild disorders of the 
gastro-intestinal tract. Finally, if artificial feeding is 
necessary, the proper modification of cows' milk should 
be used (see Chapter XVIII). 

Nursing. — If possible, children suffering from summer 
diarrhea should be sent to the seashore. They should not 
be allowed to walk, but should lie out in the fresh air as 
much as possible. 

Fresh air, quiet, proper clothing, and frequent bathing 
are essential. All soiled diapers should be immediately 
changed, the buttocks carefully washed, and the move- 
ments disinfected as described on page 470. The char- 
acter and frequency of the stools must be reported. It is 
of the utmost importance to stop the milk, as in the early 
part of the attack digestion is arrested. Small quantities 
of cold whey, barley-, or albumin-water should be fre- 
quently given. If all food is rejected or vomited, the best 
results are obtained from giving the stomach absolute 
rest. 

Maternal nursing should be withheld until twenty-four 
hours after the vomiting has ceased (which is usually 
within twelve hours). Then the physician may order a 
tentative return to the breast. The interval between nurs- 
ings should then be four hours, and only one-quarter of 
the usual quantity allowed. This may be regulated by 
allowing the infant to nurse only for two or three minutes 
at first. Between nursings whey, barley-, and albumin- 
water may be given, so that the infant takes something 
every two hours. If the indications permit, the breast- 
feeding will be gradually increased. 

When the child is artificially fed, cows' milk is absolutely 
withheld during the stage of acute symptoms, and for 



I50 DISEASES OF CHILDREN FOR NURSES 

several days after. When it is begun the physician may 
have to use various methods to render it digestible. The 
methods for carrying out any special instruction in this 
line, such as peptonizing, etc., will be found in Chapter 
XVIII. During the period when milk is suspended he 
will use such substitutes for milk as rice- or barley-water, 
wine-whey, malted soups and foods, albumin-water^ 
fresh beef-juice, animal broths, condensed milk, etc. 
The methods for preparing these foods will be found in 
Chapter XVII. 

In older children the food is withheld until vomiting 
ceases, and then broths and beef-juices given. Later, 
thin gruels made with milk, koumiss, and such foods are 
substituted. Solid foods should not be allowed for several 
days after the stools are normal. 

A proper acquaintance with the appearance and taste of 
every food ordered is essential, and a careful record of the 
amounts taken must be kept. At times the physician will 
order stimulants placed in the foods. 

No cases do worse than those in which the mother or 
nurse in charge cannot be made to appreciate the value of 
starvation, but insist upon giving food, especially milk, in 
violation of the rules laid down. 

Lavage and irrigation of the colon are essential adjuncts 
to the medicinal treatment, and the nurse must be prepared 
to apply these measures when ordered (see pages 450 and 

451)- 
The graduated cold bath will be ordered at times by the 

physician (see page 429). 

At the onset of an attack of diarrhea in summer, give 

a dose of castor oil and starve the child for twenty-four 

hours. Barley-water may be used to allay the thirst. 



DISEASES OF THE DIGESTIVE TRACT 151 

ENTEROCOLITIS, ILEOCOLITIS, OR DYSENTERY 

Of this disease there is a catarrhal^ an ulcerative^ a 
membranous^ and a chronic form. The severity of the 
symptoms is greater in the ulcerative and membranous 
forms than in the catarrhal. 

Enterocolitis may follow one of the intestinal conditions 
previously discussed, or it may be the initial disease. 

Its distinguishing symptoms are mucus and blood in the 
stools, colicky pains, and tenesmus. Often the amount of 
mucus is quite large, at times the entire movement may be 
composed of it. The characteristic appearance of mucus 
is a grayish or whitish jelly-like mass, often streaked through 
the stool. Blood rarely appears as clots, but is also streaked 
through the movement. The stools are usually small in 
size, odorless, and accompanied by a great deal of strain- 
ing, often only a teaspoonful is passed at one time. After 
the first acute symptoms are over, the blood usually disap- 
pears, but the mucus is persistent, and in all cases the 
recovery is protracted. Relapses are common, and even 
after the child has fully recovered subsequent attacks are 
easily excited by errors in diet. This is an important point 
to keep in mind, as great care must be exercised in supervis- 
ing the diet of such children ; very slight indescretions have 
produced fatal recurrences of the disease. Impress upon 
the family the importance of keeping strictly to the physi- 
cian's orders. 

A very common complication of enterocolitis is broncho- 
pneumonia, which usually produces a fatal result. 

Everything that was said in reference to the cause of 
summer diarrhea applies to enterocolitis. 

In the acute catarrhal form the mucous membrane 



152 DISEASES OF CHILDREN FOR NURSES 

of the colon is red, swollen, edematous, and in some 
cases ulcerated. 

Symptoms. — The onset is sudden. There are frequent 
stools, at first yellow, later green and mixed with curds, 
mucus, and blood, and sometimes material resembhng 
chopped spinach. Temperature ranges from 102° F. to 
103° F. The abdomen is distended and tender along the 
colon. Vomiting is rarely persistent. In the milder 
cases the mucus and blood continue to appear in the 
stools for from four to five days. The diarrhea continues 
for one or two weeks. 

In the ulcerative form the mucous membrane is 
swollen from edema and cellular infiltration. The latter 
causes superficial necrosis and formation of irregular ulcers 
which more or less undermine the surrounding mucosa. 

The symptoms of ulcerative enterocolitis are similar 
to the simple catarrhal form, but the disease is more pro- 
tracted and often marked by intermissions and exacerba- 
tions. The stools are more fluid and the mucus and blood 
persist. 

In membranous enterocolitis the mucous membrane 
is intensely swollen and covered by a false membrane. 
The separation of the membrane is followed by ulceration 
and sloughing. 

The symptoms are the general symptoms of dysentery 
plus those of the typhoid condition. The stools also 
contain false membrane and sloughs. The child grows 
pale, wastes, and assumes a senile appearance. Death 
may be preceded by coma and convulsions. 

The prognosis is always grave in membranous entero- 
colitis, yet recoveries do take place under favorable 
conditions. 



DISEASES OF THE DIGESTIVE TRACT 1 53 

Nursing of Enterocolitis. — What was said under 
Summer Diarrhea holds good in enterocolitis. In older 
children there must be absolute rest, enforced use of the 
bed-pan, and the proper restriction of the diet. The 
milk must be stopped immediately and in no instance given 
without the physician's orders. For the pain apply ex- 
ternally hot fomentations and mustard poultices. Small 
pellets of ice introduced into the rectum every two or three 
minutes for half an hour, or cold compresses applied ex- 
ternally, will frequently relieve the tenesmus. In severe 
cases of tenesmus the physician may order thin starch- 
water injections containing 10 to 20 drops of laudanum 
to the pint. Irrigation is often practised. 

In diseases of the intestines the room should be light, 
cheerful, and well ventilated. Bathing need not be 
dispensed with unless the child is too sick to stand it. 

A woolen binder worn around the abdomen is often of 
use. Cold feet should be avoided in winter, and over- 
dressing in summer is harmful. 

The feedings should be carefully prepared and the 
amount taken accurately recorded; the character of the 
stools reported, and the bowel movements covered with 
carbolic acid, 1:20 (seepage 294). 

The temperature, pulse, and respirations should be 
taken at least twice a day. 

CHOLERA INFANTUM 

This is an acute disease of childhood characterized by 
high fever, vomiting, purging, and collapse. 

It is now generally taught that the severe symptoms of 
this disease are produced by the result of a toxemia or 
poisoning of the system. The poison is produced in the 



154 DISEASES OF CHILD Ji EN FOR NURSES 

intestinal tract and absorbed. It receives its name from 
the similarity of the symptoms, in well-marked cases, to 
Asiatic cholera. 

In the majority of cases the disease attacks children 
who have been suffering from some form of intestinal 
trouble. At times children who have been perfectly well 
are stricken. 

Symptoms. — The onset may be gradual or abrupt. 
Diarrhea is usually the initial symptom. The stools are 
thin and serous or watery, and have a musty odor. Vomit- 
ing soon develops, and the irritability is so great that 
everything is rejected. The thirst is intense, and the 
temperature is very high, 105° F. to 108° F.; the pulse is 
rapid and feeble and the urine scanty. Collapse follows, 
and is indicated by the pinched features, hollow eyes, 
sunken fontanels, and the cold surface of the body. Even 
at this time reaction may set in, but, more commonly, 
death results from exhaustion. 

Treatment. — Prophylaxis. — What has been said con- 
cerning prophylaxis, under previous diseases of the intesti- 
nal tract, should be practised to avoid such a form of the 
disease as this. 

Nursing. — ^As everything swallowed during an attack 
only aggravates the vomiting, nothing should be given by 
the mouth except ice and iced champagne. 

The physician may find it necessary to wash out the 
stomach (Lavage, page 450) and irrigate the bowel 
(page 450). 

At times hypodermoclysis (see page 459) is resorted to. 
The serous or watery diarrhea so depletes the fluids of 
the body that this is necessary. 

The cold bath or tubbing is used to counteract the 
fever (page 429). 



DISEASES OF THE DIGESTIVE TRACT 155 

In collapse give a mustard tub, 110° F., then place the 
child in a horizontal position, cover with warm blankets, 
and administer stimulants freely. 

Cholera morbus is a term given to a disease, similar 
to cholera infantum, in older children. The symptoms, 
however, are not so severe. This disease is seen in the 
summer season, caused by eating unripe fruit, and sudden 
changes of temperature, such as bathing and swimming. 

Symptoms. — Intense cramps in the stomach, vomiting, 
and purging of bilious material, moderate fever, and great 
prostration. In severe cases the discharge becomes 
serous, and symptoms of collapse develop. 

FOOD INTOXICATION (FINKELSTEIN'S) 

This author has shown that certain nutritional dis- 
orders resembling profound infection are due instead to a 
failure in metabolism, and that the condition is aggra- 
vated by the ingestion of fat and sugar. 

In this type of cases it is necessary to stop all foods and 
give water in as large quantities as can be tolerated with- 
out vomiting. With cessation of the symptoms, such 
foods as broths, egg-albumin, beef-juice, buttermilk, or 
fat-free milk without additional sugar can be given. 

TUBERCULOSIS OF THE INTESTINES 

The symptoms closely resemble chronic ileocolitis. 
Ulceration occurs and the tubercle bacillus is found in the 
stools. It accompanies general tuberculosis of the body. 

APPENDICITIS 

This is an inflammation of the appendix vermiformis. 
It is a medical condition until an operation is demanded. 



156 DISEASES OF CHILDREN FOR NURSES 

There are three varieties : catarrhal^ ulcerative, and inter- 
stitial. In mild cases the appearance of the appendix is 
similar to that of catarrhal inflammation of a mucous 
membrane elsewhere. In severe forms the appendix is 
infiltrated with round cells and the mucous membrane is 
denuded of its epithelium and presents a granular appear- 
ance. This latter form may eventuate in septic peritonitis, 
chronic appendicitis with relapses {recurrent appendicitis) y 
or union of the granulating surfaces with complete obhtera- 
tion {appendicitis obliterans). 

In ulcerative appendicitis the wall of the appendix 
is the seat of a more or less localized ulcer. It may be 
associated with the presence of a fecal concretion or a 
foreign body, or it may be the result of a typhoid or 
tubercular infection. 

In interstitial appendicitis the wall of the appendix is 
the seat of a necrosis which is not infrequently gangrenous. 
It terminates by perforation, thereby exciting the most 
virulent type of peritonitis. 

The chief causes of appendicitis are exposure, errors 
in diet, intestinal catarrh with extension to the appendix, 
traumatism, lodgment in the appendix of fecal concretions 
or foreign bodies. It may follow some infectious disease, 
as typhoid, influenza, or tuberculosis. It may be induced 
by the twisting of the appendix. Any of these conditions 
will interfere with the blood-supply of the appendix, and 
this is the real reason for the inflammation. 

Symptoms. — Sudden pain, often general at first, but 
later most marked in the right iliac fossa. Localized 
tenderness, most frequently detected over McBurney^s 
pointy which is the center of the Hne drawn between the 
anterior superior spinous process of the ilium (the anterior 



DISEASES OF THE DIGESTIVE TRACT 1 5/ 

prominence on the pelvic bone) , and the umbilicus . Fever 
103° F. to 104° F. There is a localized rigidity in the 
right iliac fossa and the presence of a definite tumor. 
Dorsal decubitus with right thigh flexed. Gastro-intes- 
tinal disturbances, such as anorexia, nausea, vomiting, 
constipation, or rarely, diarrhea. 

Terminations: resolution, general peritonitis, locahzed 
abscess. 

Treatment. — Absolute rest and liquid diet. An ice cap 
should be kept constantly over McBurney^s point. Move 
the bowel only by enema. An operation is necessary at 
once in cases beginning suddenly with great severity, in 
ordinary cases where no improvement is noted after the 
lapse of forty-eight hours, when at any time there should 
be a sudden increase in the pain or a rapid diffusion of 
tenderness, and whenever a well-defined tumor can be 
detected in the right iliac fossa. 

Nursing. — Previous to operating, spreading tenderness, 
vomiting, rise or fall in the temperature, and rapidity of 
the pulse must be reported immediately. 

If ice-bags are ordered to be applied to McBurney's 
point, be sure they remain there. If vomiting occurs, the 
nurse should hold the sides of the abdomen to give as 
much relief as possible. 

The room should be well ventilated and kept at an even 
temperature. Bathing should be dispensed with. Alcohol 
sponging will relieve discomfort. 

After the operation the child should be kept flat on the 
back. The dressing should be carefully watched. Ab- 
solutely nothing should be given by the mouth without a 
physician's orders. The temperature, pulse, and respira- 
tion should be taken every three hours throughout the 
attack. 



158 DISEASES OF CHILDREN FOR NURSES 

In septic cases the surgeon may order the child to be 
placed in a semireclining or sitting position after operation 
for purposes of drainage. 

This can be maintained by a bed-rest and some con- 
trivance to keep the child from slipping. A simple plan 
of procedure under these conditions is to take the seat of a 
swing, bore four holes, one at each corner, through which 
are passed the ends of four lengths of rope, which are 
securely knotted on the under side. After the desired 
position of the seat on the bed has been determined, the 
two lower ropes are tied to the head of the bed at the level 
of the mattress. The seat is then tilted to the proper 
angle, and the two upper ropes are tied to the top of the 
back of the bed. 

The seat is then covered with a pillow upon which rests 
the child's buttocks. His legs are flexed over the edge of 
the seat, and his feet rest on a hot-water bag. This 
apparatus gives them a feeling of security and the angle of 
the seat may easily be changed by loosening or tightening 
the upper ropes. 

Continuous saline irrigation of the bowel may be ordered 
(for method, see page 451). 

INTESTINAL OBSTRUCTION 

Intestinal obstruction is a condition in which the bowel 
becomes closed, preventing the passage of feqal material. 

Causes. — Acute causes are congenital occlusion, intus- 
susception, internal or external strangulation, and twists. 

Chronic obstructions are: stricture from healing ulcer; 
unnatural accumulations, as of fecal masses ; foreign bodies; 
gallstones; and tumors pressing from within or without. 



DISEASES OF THE DIGESTIVE TRACT 1 59 

Congenital occlusion is usually located at the anus or 
rectum (see page 142). 

Intussusception is the slipping of a portion of the 
intestines into another portion immediately below it. 
This usually occurs at the ileocecal valve, the small 
intestines sHpping into the large. This is due to unequal 
muscular contraction and an elongation of the mesentery 
(the attachment of the intestines to the abdominal wall). 
The invagination cuts off the blood-supply, and gangrene 



Fig. 41. — Schematic representation of an ileocecal invagination. The mucous mem- 
brane is indicated by the dotted line (Friihwald and Westcott). 

occurs. Unless promptly reduced, death occurs from 
this cause. 

Symptoms. — The onset is often sudden. There may 
be a few loose stools, composed mostly of blood and 
mucus. At first there is paroxysmal pain in the side. 



l60 DISEASES OF CHILDREN FOR NURSES 

Later this becomes continuous. Vomiting almost imme- 
diately sets in and is at first bilious, but after the obstruc- 
tion is complete, it becomes fecal (stercoraceous). It is 
persistent, and everything that enters the stomach is 
immediately rejected. At first the abdomen is retracted, 
but it soon becomes distended, and the presence of a 
sausage-shaped tumor may be detected at the site of the 
intussusception. Prostration is marked. The tempera- 
ture ranges between 103° F. to 104° F. If gangrene 
occurs, the child dies of peritonitis. 

Treatment. — High rectal enemas of large quantities of 
water or salt solution at times forces the bowel back and 
reduces the intussusception. In giving such enemas the 
buttocks should be well raised and the bottom of the 
bag four feet above the table. If this does not accom- 
plish the result, an immediate operation is demanded. 

Strangulation. — This occurs where there is a hernia 
or rupture. It may occur externally where the bowel 
sHps through the abdominal ring, or internally if a portion 
of the gut slips through an opening in the diaphragm 
or under an adhesion. All of these conditions become 
strangulations where for any reason the bowel is com- 
pressed and the passage of feces stopped. 

Twists or volvulus are found in the sigmoid flexure. 
They are true twists of the bowel, due to a relaxed mesen- 
tery. 

Symptoms of acute obstruction are sudden and at first 
consist of paroxysmal pains, later becoming continuous. 
There is constipation; vomiting, persistent and becoming 
stercoraceous; abdominal distention; and collapse. 

Treatment. — An immediate operation is imperative. 

Chronic Obstructions. — Healing ulcers form scars 



DISEASES OF THE DIGESTIVE TRACT l6l 

which contract and act as a band constricting the intes- 
tines. Unnatural fecal masses, foreign bodies, and gall- 
stones may obstruct by their bulk. Tumors may press 
upon the intestines, in this way compressing them, or 
tumors growing within the intestines may obstruct by 
their bulk (uncommon in childhood). 

The symptoms of chronic intestinal obstructions develop 
slowly and are the same as those found in the acute form. 

ANIMAL PARASITES 

Animal parasites or intestinal worms are tape-worms 
(ta3nia soHum and taenia saginata), round worms (ascaris 
lumbricoides), and seat worms (oxyuris vermicularis.) 

Tape-worms are formed of white segments. They 
are flat and may be from ten to fifteen feet in length. 
They gain entrance to the intestinal canal through un- 
cooked beef or pork. The taenia saginata or beef-worm is 
the most common in children. 

Symptoms. — Various nervous symptoms exist. Anemia, 
if the worm is not expelled, and at times an inordinate 
appetite. Segments are seen in the stools. 

Treatment. — The thorough cooking of all meats. If 
segments are discovered the child should be treated as 
follows: a Ught supper, and the following morning a 
saline purge, without any breakfast. After the purge has 
acted give oleoresin of male fern, 15 minims, in capsule, 
one every hour for four hours. Fifteen minutes after the 
last dose give castor oil. Milk should be the diet for the 
rest of the day. 

It is absolutely necessary that the head of the worm 
should be recovered, for even though all the body is passed, 
if the head remain the worm will grow again. The 



l62 



DISEASES OF CHILDREN FOR NURSES 



subsequent stools should be closely watched. The head 
is very much smaller than the body and is attached to the 
neck, which gradually grows smaller as the head is ap- 
proached. At the time of the expected passage of the worm 
it is well to half fill the receptacle with water. This per- 
mits the worm to float and avoids the breaking from its 
own weight. To recover the head a piece of muslin or 
fine mesh gauze should be stretched over a vessel and the 
movement poured into this. 





Fig. 43. — Ascaris lumbricoides (Kerr). 



a b 

Fig. 44- — Teniae: (a) Head 
and first segments; (i) middle 
segments (Kerr). 



Ascaris Lumbricoides (Round-worms).— These worms 
are from five to ten inches in length and about as thick 
as a slate pencil. They are grayish-pink in color and are 
pointed at both ends. Usually six to a dozen are present 
in the bowel. 

The symptoms are variable, nervous symptoms being the 



DISEASES OE THE DIGESTIVE TRACT 1 63 

most marked. The worms are often found in the stools. 
They have a tendency to migrate, and are at times vomited. 

Treatment. — Santonin, gr. 3, to a child of five, given 
in three doses at four-hour intervals. The same plan of 
treatment as described under tape-worms should be fol- 
lowed, with the exception of santonin being used instead 
of male fern. 

Oxyuris Vermicularis (Seat-worms). — These are small 
thread-worms about one-third inch in length. They occur 
in great numbers and inhabit the colon and rectum. 

Symptoms. — Intense itching of anus, especially at night, 
and the appearance of the worms at anus. 

Treatment. — The use of bichlorid of mercury, i to 
10,000 after stool. Wiping the parts thoroughly and the 
injection of bichlorid of mercury, i to 10,000, into the 
rectum will cure mild cases. Infusion of quassia is also 
used. Some cases are very troublesome. Blue ointment 
will reheve the itching. 

Uncinaria Duodenalis (Hook-worms). — These are 
small thread-like worms, about three-quarters of an inch 
long, which attach themselves by means of four teeth to 
the mucous membrane of the small intestines, especially 
in the jejunum. 

The loss of blood due to thousands of these worms being 
"hooked" to the lining of the intestines causes a severe 
and at times a fatal anemia. It is one of the most danger- 
ous parasites met with in the human body. It is found in 
Egypt, Germany, Italy, Belgium, Switzerland, the West 
Indies (Jamaica), and through the southern portion of the 
United States. 

The children affected become dull, listless, emaciated, 
and profoundly anemic. 



164 DISEASES OF CHILDREN FOR NURSES 

The ova and embryos are contained in the stools, and 
are disseminated through dirt. 

Treatment and Nursing. — Thymol is given to destroy 
the worms. Following its administration castor oil will 
usually expel large numbers of dead worms. The stools 
should be thoroughly disinfected (see page 470). 

DISEASES OF THE RECTUM 

Prolapse of Rectum. — This may be partial or complete. 

A simple eversion of the mucous membrane or a protru- 
sion of three or four inches of the bowel. It occurs at stool. 

Treatment. — This can usually be replaced by gentle 
pressure with oiled fingers. Cold water will reduce 
congestion and assist in an obstinate reduction. To 
prevent recurrence have the child defecate upon its back, 
holding buttocks close together. In the more severe 
forms surgical treatment is demanded. 

Fissure of the anus is a small linear ulcer of the mucous 
membrane covering the sphincter. It is very annoying 
and irritating. 

Treatment. — Cleanliness and touching the ulcer with 
a silver stick will promptly cure. 

Ischiorectal abscess is an abscess in the tissues sur- 
rounding the rectum. 

Hemorrhoids or piles are the engorgement of the 
veins of the rectum. They may be internal or external. 
They give rise to pain at stool, and are not common in 
children. Cold-water injections give relief. 

Incontinence of feces is the name given to the in- 
ability to control the evacuations. 

Proctitis. — This is an inflammation of the rectum. 
When it occurs alone it is caused by the use of suppositories, 
injections, and seat-worms. 



DISEASES OF THE DIGESTIVE TRACT 1 65 

The principal symptoms are the passage of mucous and 
bloody stools with tenesmus. 

Nursing. — The tenesmus is relieved by the introduc- 
tion of pellets of ice into the rectum, or by means of a 
simpler method which is probably just as effective— the 
application of cold compresses to the anus. 

Do not take the temperature by way of the rectum if it is 
diseased. 

Give rectal irrigations slowly to avoid pain. 

Diseases of the Liver 

Jaundice is a pigmentation of the skin and tissues 
with bile-pigment. It is caused by an obstruction to the 
flow of bile from the liver, through the common bile-duct, 
into the intestines. This obstruction in children is usually 
due to congestion or inflammation of the common bile-duct, 
the process being an extension from the small intestines. 
This obstruction prevents the bile from passing through 
its natural channels, so that it is backed up and thrown 
into the circulatory system and carried to all parts of the body. 

The symptoms of jaundice are the yellow hue to the 
skin and conjunctiva of the eye; the latter is distinctive. 
The urine is dark and the stools are light. 

Icterus neonatorum is jaundice of the newborn infant. 

Catarrhal jaundice is the name appHed to an acute 
catarrhal inflammation of the common bile-duct usually 
caused by extension from the bowel, characterized by the 
symptoms of gastro-enteritis plus jaundice. 

Gallstones are concretions formed in the gall-bladder 
and composed for the most part of bile elements. These 
stones may He latent, pass out along the common bile-duct, 
causing biHary cohc, or may become impacted in the 



1 66 DISEASES OF CHILDREN FOR NURSES 

duct, giving rise to grave symptoms which demand an 
operation. This is not common in childhood. 

Symptoms of biHary coHc are sudden and intense pain 
over the hver, radiating to the right shoulder. This 
usually occurs an hour or two after eating. A chill with 
fever may marl^ the onset. Jaundice may be present 
from obstruction and the stone may be found in the 
stool. 

Cholecystitis is inflammation of the gall-bladder. 

Congestion of the liver may be active or passive, just 
as in the lungs. Active from arterial blood (too much 
blood from heart to the liver) ; passive from venous blood 
(obstruction to return of blood to heart). 

Cirrhosis of the liver is a chronic disease characterized 
by an overgrowth of connective tissue and a destruction 
of the hver-cells. 

There are two varieties, an atrophic form in which there 
is general contraction of the connective tissue in the Hver 
and the organ becomes very much reduced in size. 

A hypertrophic form in which there is no contraction of 
the connective tissue, but since the connective tissue is 
largely increased the Hver actually enlarges. 

Abscess and cysts of the liver are seen. 

Diseases of the Spleen 

The spleen is enlarged in a number of conditions, the 
most frequent of which are malaria, typhoid, rickets, 
syphilis, and tuberculosis. 

It is also seen in simple anemia accompanied by 
moderate leukocytosis, in von Jaksch's disease, in leu- 
kemia, and Hodgkin's disease. In the last two the 
liver is also enlarged. 



DISEASES OF THE DIGESTIVE TRACT 1 6/ 

It may accompany any of the acute infectious diseases; 
it is seen in amyloid degenerations ; and in cardiac condi- 
tions in which there is obstruction to the venous circula- 
tion. 

The spleen has been removed in cases of pernicious 
anemia with very good results. 

. Peritonitis 

This is an inflammation of the peritoneum. It may 
be primary, or secondary to some inflammation of the 
surrounding parts. It may be localized or general. It 
may have a serofibrinous, fibrinous, or purulent exudate. 
It may be acute or chronic. 

Acute peritonitis is caused by exposure to cold and 
wet, traumatism or injury, and by extension of the in- 
flammation from some adjacent structure, such as typhoid 
ulcer or appendicitis. It may be secondary to some 
general disease such as scarlet fever, rheumatism, or 
tuberculosis. 

Symptoms. — The disease starts with a chill and fever, 
102° F. to 103° F. There is a rapid, wiry pulse, abdomi- 
nal pain, and tenderness so intense that abdominal 
respirations and body movements are inhibited. The 
child lies on its back with the thighs flexed, the features 
are pinched, the vomiting is persistent, the bowels are 
constipated. Hiccough is a common and troublesome 
symptom, the abdomen is greatly distended and is hard 
and board-like. In the large majority of cases death 
occurs in a few days. 

Nursing. — The room should be kept at an even tem- 
perature; the bed-clothes should be supported by a frame 
over the abdomen. 



1 68 DISEASES OF CHILDREN FOR NURSES 

The child should be carefully watched; any movement 
will cause excruciating pain. Bathing should be stopped. 
Champagne is often the only substance which will be re- 
tained. Cracked ice will alleviate the thirst. Drugs 
are often administered hypodermically. 

If the child vomits, hold the sides of the abdomen to give 
as much relief as possible. 

The temperature, pulse, and respirations should be 
taken every three hours. 

Chronic peritonitis may occur unassociated with 
tuberculosis. It is usually a locahzed peritonitis; if gen- 
eral, it is associated with fluid in the abdomen. 

Tubercular Peritonitis.— -The large majority of cases of 
chronic peritonitis are tubercular in character. It is 
usually associated with general tuberculosis or due to 
tuberculosis of the mesenteric lymph-glands. 

Symptoms. — The abdomen usually contains fluid and 
there is an evening rise of temperature; emaciation and 
weakness are marked. The pain is not so severe as in 
the acute form of peritonitis, but there is diffuse tenderness. 
There are evidences of tuberculosis in the other organs. 

Treatment. — It is in these cases that opening the 
abdomen is of such value. 

ASCITES 

Ascites is a dropsical condition of the peritoneum in 
which there is a serous effusion into the peritoneal cavity, 
usually a part of general dropsy. 



CHAPTER VIII 

DISEASES OF THE CIRCULATORY SYSTEM 

Anatomy. — The heart is a hollow, conic muscle nor- 
mally situated in the left chest. 

It is divided by muscular and fibrinous partitions into 
four cavities. The two upper chambers are called the 
right and left auricles, and the two lower, the right and 
left ventricles. 

The right auricle is connected by an opening with 
the right ventricle called the tricuspid orifice. This 
passage is closed by the tricuspid valve, so-called because 
it has three leaflets. 

The right auricle contains the orifice of the superior 
and inferior vena cava. This opening is surrounded 
by a sphincteric muscular band to prevent a back-flow 
of the blood. 

The left auricle opens into the left ventricle by the 
mitral orifice, which is closed by the mitral valve, so 
called because it resembles a bishop's miter. The function 
of the valve is to prevent a return flow of blood to the 
chamber it has left. 

The left auricle contains the orifice of the pulmonary 
vein. 

The right ventricle contains the orifice of the pul- 
monary artery. This is closed by the pulmonary semi- 
lunar valves. 

i6q 



170 



DISEASES OF CHILDREN FOR NURSES 



The left ventricle contains the orifice of the aorta, 
closed by the aortic semilunar valves. 

The valves are made of thin fibrous tissue and 
covered by the endocardium. They are attached to the 
heart-muscle walls by the corda tendincB, little filaments 
of muscular tissue. Normally, the valves perfectly close 




Fig. 4.5. — Right auricle and ventricle opened: i, Superior vena cava; 2, inferioi 
vena cava; 3, right auricle; 4, cavity of right ventricle; 4', papillary muscles; 5', 5". 
s'", tricuspid valve ; 6, pulmonary artery and semilunar valve ; 7, 8, aorta ; 10, left au- 
ricle; II, left ventricle. (Allen Thomson). 

the orifice at which they are situated after the column of 
blood passes that point. 

The endocardium is the lining membrane of the 
heart. It covers the inner walls of all the cavities and 
both sides of the leaflets of the valves. 



DISEASES OF THE CIRCULATORY SYSTEM 1 71 

The pericardium is a serous membrane and forms 
a sack in which the heart is contained. It is Kke the 
pleura and covers the heart in a similar manner as that 
membrane does the lungs. One portion covers the 
heart-muscle intimately, being firmly attached to it; and 
the other portion is reflected, forming a closed sack. 
Betvi^een the two layers there is about one ounce of a 
serous fluid which lubricates the opposing surfaces. 

The broad upper portion of the heart is called the 
hase and the lower pointed portion, the apex. 

The heart beats rhythmically from an inherent prop- 
erty of its muscle and from nervous control. The pneu- 
mogastric nerve carries the principal fibers to it. 

When the heart-beat is heard or felt the ventricles 
empty. This is called systole. The auricles empty be- 
tween beats. This is called diastole. 

The Circulation. — The blood enters the right au- 
ricle from the superior and inferior vena cava. It then 
passes through the tricuspid orifice to the right ventricle. 
From the right ventricle the course is through the pulmo- 
nary artery (the only artery in the body carrying venous 
blood) to the lungs, where it is purified and changed into 
arterial blood. It returns to the left auricle through the 
pulmonary vein, the only vein carrying arterial blood. 
From the right auricle the blood passes through the mitral 
orifice to the left ventricle and is then pumped into the 
aorta. The aorta suppHes the general arterial circulation, 
distributing the blood through its divisions and subdivisions 
to all parts of the body. The arteries become smaller and 
smaller, until they become capillaries. Here the arterial 
blood is changed into venous blood. The venous blood 
is collected from the capillaries, emptied into veins, which 



I ^2 DISEASES OF CHILDREN FOR NURSES 

become larger and larger, and finally flows into the 
superior vena cava (the head, neck, and upper extremities) 
or into the inferior vena cava (the trunk and lower ex- 
tremities). The vena cava empties into the right auricle. 
The time taken for a complete circulation of a drop of 
blood in a newly-born child is twelve seconds; at three 
months, fifteen seconds; in the adult, twenty-two seconds 
(Vierordt). 

The Fetal Circulation. — This is the circulation of the 
blood in the fetus. It differs from circulation after birth 
in that the blood is purified in the placenta and not in the 
lungs of the child. The placenta is attached to the walls 
of the womb and is expelled at birth, being called the 
ajter-birth. 

Before birth the right and left auricles are connected 
by an opening called the foramen ovale. A large portion 
of the blood passes through this foramen directly into the 
left auricle. A smaller quantity passes through the tri- 
cuspid valve into the right ventricle. 

At birth the umbilical cord is ligated and breathing 
is instituted in the child. The blood then ceases its flow 
to the placenta and the pulmonary circulation becomes 
of great importance. The circulation from this moment 
is the same as in after life. The passage through the 
foramen ovale and the ductus arteriosus becomes unneces- 
sary, and, normally, these two openings are closed. The 
foramen ovale is almost closed at birth and entirely closed 
within six months after delivery. The ductus arteriosus 
closes in about ten days. 

At times these openings remain patulous, they fail to 
close, and the fetal circulation persists after birth. This 
allows the venous blood in the right side of the heart to 



DISEASES OF THE CIRCULATORY SYSTEM 1 73 

enter the arterial system, giving rise to what are known as 
hlue babies. Before birth the sharp distinction between 
venous and arterial blood does not exist in the heart. 

Malformations. — The patulous ductus arteriosus and 
foramen ovale constitute a deformity of the heart when 
they persist after birth. The infants affected are more or 
less cyanosed or blue in color, especially about the hps and 
finger-nails. There are periods when this is more marked 
than at other times. They are poorly nourished and 
usually die in the first few months, if not from weakness 
of the heart, from some intercurrent condition. At times 
they live, the openings closing late and the normal circula- 
tion being estabHshed. 

Abnormalities in the origin of the large vessels are 
sometimes seen. 

Transposition of the heart is sometimes noted. In this 
condition the heart is found on the right side instead of 
the left. 

Fetal Endocarditis. — This is an inflammation of the 
lining of the heart which occurs before birth. It is 
nearly always the right side of the heart that is affected. 
After birth inflammations of the endocardium attack the 
left side. The fetal inflammation causes valvular lesions 
at the tricuspid and the pulmonary orifices, the children 
being bom with these defects. It is safe to say that val- 
vular lesions of the right side of the heart are always 
congenital. 

Phenomena of the Action of the Heart. — The apex- 
beat is a pulsation caused by the apex of the conic- 
shaped muscle of the heart coming in contact with the 
chest wall. After seven years of age it is normally situated 
in the fifth intercostal space, one-half to one inch inside 



174 DISEASES OF CHILDREN FOR NURSES 

of the mammary line. Before this time it is found higher 
and further to the left. 

The apex-beat may be displaced by such conditions 
as a pericardial effusion, a hypertrophy or dilatation of 
the heart, or the pressure from either side from such 
conditions as a pleural effusion, tumors, etc. Changes 
are noted in the force and extent of the apex-beat under 
similar conditions. 

The normal area of heart dulness obtained by per- 
cussion is from the junction of the third rib, with the 
sternum on the left side, to the apex-beat which can 
usually be seen in the fifth interspace, from one-half to one 
inch inside the mammary Une, from the apex-beat to the 
xiphoid cartilage (the lower end of the sternum or breast- 
bone), and thence up the right border of the sternum to 
the level of the third rib. 

The two sounds heard over the heart upon ausculta- 
tion are caused as follows: The first results from the 
contraction of the ventricle and the impact of the heart 
against the chest wall, and is synchronous with the apex- 
beat (called the systolic sound). The second sound is 
caused by the closure of the aortic and pulmonary valves 
{diastolic). The first sound is long and booming, and 
between it and the second sound there is a slight pause. 
The second sound is short and high pitched. After the 
second sound a long pause follows before the first sound is 
repeated; characterized by "lubb, tub." Any alteration 
in the character of either of these sounds is spoken of as 
a murmur. Accentuation of the sounds does not con- 
stitute a murmur. If the murmurs are due to a disease 
of the heart proper they are spoken of as endocardial 
murmurs. If due to anemia they are called hemic mur- 



DISEASES OF THE CIRCULATORY SYSTEM 1 75 

murs. In pericarditis they are called friction sounds, 
and in aneurism, hruit. 

A hemic murmur is a soft, blowing sound heard over 
the base of the heart. They do not indicate any damage 
to the valves; only an alteration of the blood, such as the 
diminution of hemoglobin found in anemia. 

Flint'' s murmur is the name given to a sound heard lq 
aortic regurgitation, due to the mitral leaflets vibrating 
between the column of blood passing through the 
mitral orifice and the column leaking back from the 
aorta. 

The locations where the different valve sounds are 
best heard are: 

Mitral, at the apex; tricuspid, at the end of the 
sternum (xiphoid cartilage) ; aortic, second costal cartilage, 
about an inch to the right of the sternum; pulmonary, 
second costal cartilage, about an inch to the left of the 
sternum. 

The Pulse. — At birth the pulse is between 130 to 150 
per minute, in the second year about 100, and gradually 
lessens as the child matures. An adult has a pulse of 
70 or 80 per minute. 

There are several changes which take place in the 
pulse which have received different terms. 

Tachycardia, an increased frequency of the pulse. 

Bradycardia, infrequency of the pulse. 

Intermittent, dropping a beat. 

Irregular pulse, alternately rapid and slow. 

A dicrotic pulse is one in which the main beat is 
quickly followed by a secondary wave or a slight rebound 
of the vessel. It is seen in the cases where there is a low 
arterial tension, especially in febrile diseases. It may 



176 DISEASES OF CHILDREN FOR NURSES 

cause the mistake of counting double the number of 
beats actually present. 

A high-tension pulse is one in which the force 
of the beat is relatively increased. The tension 
of the pulse may be estimated roughly by noting 
the amount of pressure of the fingers that is required 
to arrest the beat. A low tension pulse is just the op- 
posite. 

Venous pulse ^ when present, is usually found over the 
jugular vein. It is rare. 

Asymmetric Radial Pulse. — When the two radial 
beats are not synchronous it may be due to conditions 
affecting one side of the circulation, as aortic aneurisms, 
fractures, luxations, etc. 

Water-hammer pulse is characterized by short, power- 
ful beats which suddenly collapse. It is seen in aortic 
regurgitation (see page 183). 

Other conditions which are present in diseases of the 
heart beside the alteration of the apex sounds and pulse 
above noted, are: 

Palpitation, which is a rapid tumultuous action of 
the heart perceptible to the patient. This condition is 
termed a functional disorder. 

Dropsy. — An unnatural collection of serous fluid in 
the tissues of the body. 

General Cyanosis. — Blueness of the surface from 
insufficient oxidation of the blood. 

Clubbing of the fingers in chronic cases. 

PERICARDITIS 

This is an inflammation of the pericardium or serous 
covering of the heart. It is rare in infancy, but as the 



DISEASES OF THE CIRCULATORY SYSTEM 1 77 




Fig. 46 — The "clubbed fingers" of chronic heart disease. 





Fig. 47. — Clubbing of toes in chronic heart disease. 



child grows older it is not uncommon. It follows pleuro- 
pneumonia, rheumatism, the acute infectious diseases, 
pyemia, tuberculosis, and local causes. 



178 



DISEASES OF CHILDREN FOR NURSES 



Pathology. — -The same conditions exist in pericarditis 
as in inflammations of a serous membrane in any other 
part of the body. At first the surfaces are red and sticky; 
they rub together and cause a great deal of pain. In a 
day or two an effusion appears, which may be serous, 
serofibrinous, fibrinous, or purulent. 

In the serofibrinous jorm there is little lymph and a 
great deal of serum, which, in favorable cases, is absorbed. 

In the fibrinous jorm, just as in pleurisy, the surfaces 




Fig. 48. — Large pericardial effusion. Area of dulness in solid black. Normal area of 
absolute cardiac dulness lined (Kerr). 



are covered with a butter-like exudate which may organize 
and form adhesions. In the purulent form death is 
usually the result. 

Symptoms. — Moderate fever, precardial pain and 
tenderness, dyspnea, and palpitation. The pulse is at 



DISEASES OF THE CIRCULATORY SYSTEM 1 79 

first rapid and forceful, but later weak and irregular. 
The signs of the effusion will appear on the second or 
third day, and there will be relief from pain in all but the 
fibrinous form, where it is apt to be intensified, owing to 
the adhesion of the two surfaces. The disease lasts from 
one to three weeks. 

In the adhesive form of pericarditis, more or less per- 
manent enlargement of the heart results. 

Treatment. — The physician may tap the effusion, in 
which case the nurse should prepare for the operation in 
the same manner as described for aspirating the chest 
(see page 87). the precardia being the point of insertion 
instead of the axilla. 

Other affections of the pericardium noted are: 

Hydropericardium, dropsy within the pericardial sac; 
hemopericardium, blood within the pericardial sac; pneu- 
mopericardium, air within the pericardial sac. 

ENDOCARDITIS 

Endocarditis is an inflammation of the lining mem- 
brane of the heart. The process is usually confined to 
the valves. 

Varieties. — Vegetative, in which are found numerous 
bead-like vegetations that are especially marked along 
the free border of the valve. The valve itself is red and 
swollen. These vegetations are composed of connective 
tissue and fibrin, the latter derived from the blood. They 
may be whipped off by the blood current and may be 
carried as emboli to distant organs, such as the brain, 
kidney, or spleen. But more commonly if Hfe is pre- 
served they are partially absorbed and fibrous tissue forms, 
causing a hardening or sclerosis of the valve leaflets. 



1 80 DISEASES OF CHILDREN FOR NURSES 

This forms the second variety of endocarditis, the so- 
called sclerotic or chronic endocarditis. The latter may 
arise as a primary disease, and is then characterized by 
the thickening, curhng, and puckering of the valves from 
an overgrowth of the fibrous tissue. 

The third variety is the so-called malignant or ulcera- 
tive endocarditis. 

Acute endocarditis usually results from acute artic- 
ular rheumatism, one of the infectious fevers, chorea, 
or septicemia. Forty per cent, of the cases of articular 
rheumatism have associated endocarditis. Of the infec- 
tious fevers, pneumonia and scarlatina are most prone to 
heart comphcations. The young are more Hable to be 
attacked than the old. 

Chronic endocarditis may be congenital, the right 
side of the heart being then affected. It may follow an 
acute attack or it may result directly from syphilis, rheu- 
matism, or Bright's disease. Severe muscular strain some- 
times induces it in older children. 

After birth endocarditis most commonly involves the 
valves of the left side of the heart. 

Symptoms of Acute Endocarditis. — Subjective phe- 
nomena, such as pain, fever, cough, and dyspnea, are 
frequently absent, and auscultation may be the only means 
of diagnosing the disease, should a murmur be found. In 
many cases fever, an irregular and rapid pulse, palpitation, 
precordial distress, and dyspnea are associated symptoms. 

To understand the conditions which cause valvular 
lesions of the heart the pathologic changes which take 
place in endocarditis should be kept in mind. 

It is safe to say that in the majority of cases which 
survive the acute attack the sclerotic form of endocarditis 



DISEASES OE THE CIRCULATORY SYSTEM l8l 

exists. The sclerotic form is an overgrowth of fibrous 
tissue which causes the leaflets of the valves to become 
swollen and permanently thickened. This enlargement 
of the leaflets obstructs the valvular orifice. This is the 
case in the so-called stenosis or obstructive valvular con- 
ditions. This fibrous tissue sometimes contracts, in which 
condition the valve becomes wrinkled, puckered, and 
curled up. It is then easily discernible that a valve thus 
affected could not close the valvular orifice completely, and 
the blood leaks back into the chamber it has just left. This 
is the condition found in insufficiencies or regurgitations. 

As there are four valves to the heart — aortic, pul- 
monary, mitral (left side), and tricuspid (right side) — 
there may be an aortic stenosis or an aortic regurgitation ; 
a pulmonic stenosis or a pulmonic regurgitation; a mitral 
stenosis or a mitral regurgitation; a tricuspid stenosis, 
or a tricuspid regurgitation. 

Murmurs. — A murmur is any alteration in the nor- 
mal sound of the heart. (Accentuation of sounds is 
not considered a murmur.) A murmur is produced by 
the blood flowing over a roughened or damaged valve. 
In an obstruction to an orifice the opening is too small, 
and in forcing the blood through the narrow passage it 
produces a blowing sound or murmur. In insufficiencies 
where the valve is not tightly closed there is a leakage 
back into the chamber of the heart from which the blood 
has been pumped after the valves are closed. 

This passage of blood through the leak causes the 
same blowing sound or murmur. 

The murmur occurs at the time the blood passes 
through the damaged valve. In obstruction it is at the 
time the blood is flowing from the chamber into the next 



1 82 DISEASES OF CHILDREN FOR NURSES 

portion of the circulation. If the obstruction is at the 
orifice between the auricle and the ventricle, it is at the 
moment the auricle is emptying itself into the ventricle. 
If the obstruction is at the entrance to the aorta or pul- 
monary artery, the murmur occurs when the ventricle is 
emptying into the vessels. 

In regurgitations the orifice is not too narrow, but 
rather larger than normal, the valves being wrinkled up; 
so there is no murmur when the blood is passing from one 
chamber into the next part of the circulation. When the 
valves close to prevent back-flow, they do not close the 
opening entirely; consequently there is leakage into the 
chamber from which the blood has just passed. This 
leak is small and it causes a murmur at the time when 
the valves should be closed. 

The time when the various phenomena of the heart's 
action occurs is divided into systole and diastole. 

Systole is the time when the ventricles empty, the 
blood flowing into the aorta and the pulmonary artery. 
The mitral and tricuspid valves are closed to prevent the 
blood from flowing into the auricles. The auricles fill 
while this is taking place. 

The heart-heat occurs at this time, demonstrated by 
the apex-beat, the pulse wave, and the first sound of the 
heart. 

Diastole is the time when the aortic and pulmonary 
valves close to prevent the blood from flowing back into 
the ventricle, causing the second sound of the heart; the 
mitral and tricuspid valves open, and the blood flows 
from the auricles into the ventricles. The time of the 
different murmurs is as follows: 

Mitral stenosis or obstruction occurs when the blood 



DISEASES OF THE CIRCULATORY SYSTEM 1 83 

is flowing from the left auricle into the left ventricle. The 
time is diastolic. As the greatest contraction of the 
auricle occurs late in the diastole the murmur is heard 
best at that time. It is called a late diastolic murmur, 
or, more often, presystolic. It is heard just before the 
first sound of the heart at the apex. 

Mitral regurgitation or insu-jficiency occurs when the 
blood should be flowing from the left ventricle into the 
aorta. A portion leaks back through the damaged mitral 
valve. The time is systolic. It is heard instead of the 
first sound at the apex. 

Aortic stenosis or obstruction occurs when the blood 
flows from the left ventricle into the aorta. The time is 
systolic. It is heard instead of the first sound at the 
aortic area, the second costal cartilage to the right of the 
sternum. 

Aortic regurgitation or insufficiency occurs when the 
aortic valves should be completely closed. This leak 
allows the blood to flow back into the left ventricle. The 
time is diastolic. It is heard instead of the second sound 
of the heart at the aortic area. 

Tricuspid stenosis or obstruction occurs when the blood 
is flowing from the right auricle into the right ven- 
tricle. The time is late diastohc or presystoHc. It is 
heard just before the first sound at the end of the sternum 
(xiphoid cartilage). 

Tricuspid regurgitation or insufficiency occurs when 
the blood should be flowing from the right ventricle into 
the pulmonary artery, and the tricuspid valve is closed, 
A portion leaks through the damaged valve into the right 
auricle. The time is systohc. It is heard instead of the 
first sound at the end of the sternum. 



1 84 



DISEASES OF CHILDREN FOR NURSES 



Pulmonary stenosis or obstruction occurs when the 
blood is flowing from the right ventricle into the pulmonary 
artery. The time is systohc. It is heard instead of the 
first sound at the pulmonary area, at the second costal 
cartilage, one inch to the left of the sternum. 

Pulmonary regurgitation or insufficiency occurs when 
the pulmonary valve is closed to prevent the back-flow of 
blood into the right ventricle. The damaged valve per- 
mits a portion of the blood to leak back into the right 
ventricle. The time is diastolic. It is heard instead of 
the second sound at the pulmonary area. 

Double murmurs are heard when one or more lesions 
exist, the valves affected being determined by the time 
of murmur, and the location where they are best heard. 
Under such conditions both a systoHc and a diastolic 
murmur can exist. 

Reduplication of the second sound is due to the fact 
that the aortic and pulmonary valves do not close simultan- 
eously, the closure of both valves being heard. 

Mitral regurgitation is the most common valvular 
lesion. 



Table of Heart Murmurs 



Lesion 


Systolic 


Diastolic 


Presystolic 


Heard best 


Mitral stenosis 






-f- 


Apex 


Mitral regurgitation 


+ 






Apex 


Aortic stenosis 


+ 






Aortic cart. 


Aortic regurgitation 




+ 




Aortic cart. 


Tricuspid stenosis 






+ 


Xiphoid 


Tricuspid regurgitation 


+ 






Xiphoid 


Pulmonary stenosis 


+ 






Pul. cart. 


Pulmonary regurgitation 




+ 




Pul. cart. 



The period of compensation means an increase in the 
size and strength of certain cardiac chambers, sufficient 



DISEASES OF THE CIRCULATORY SYSTEM 1 85 

to enable the arterial system to receive its normal amount 
of blood, notwithstanding obstruction or regurgitation at 
one or more valves. 

The duration of this period is indefinite, and depends 
largely upon the amount of damage sustained by the 
heart and the hygienic conditions to which the patient is 
subjected. It is Nature's way of overcoming the damage 
done. In the lung this is accompHshed by compensatory 
emphysema; in the heart the same amount of work has 
to be continuously accompHshed. If a portion of the 
heart is disabled, the rest of the heart has to do the extra 
work, and therefore becomes enlarged and hypertrophied. 
During perfect compensation the murmur is usually the 
only sign of the endocarditis. People frequently go 
through hfe with a murmur and hve as long as those who 
are not so unfortunate. As long as there is perfect com- 
pensation there is no danger to the life of the patient. 

Periods of lost compensation usually result from 
increased damage to the valves, conditions leading to 
arterial and cardiac degeneration, some intercurrent 
disease throwing additional strain upon the heart, and 
undue physical exertion. 

During this period the subjective symptoms reappear. 
This loss of compensation gives rise to dilatation of the 
heart and cardiac insufficiency. No matter what the 
original valvular lesion may have been, the organ becomes 
unable to fill the arteries and the blood is dammed back 
in the lungs and venous congestion of the organs follows. 
Very frequently the heart will readjust itself and com- 
pensation will return. 

Acute ulcerative endocarditis is a rapidly destruc- 
tive form of endocarditis and is characterized by necrosis 



1 86 DISEASES OF CHILDREN FOR NURSES 

or ulceration of the valves. It usually follows septicemia 
or one of the infectious fevers, such as pneumonia, erysipe- 
las, or scarlet fever. It may arise as a primary condition. 
The valves are the seat of ulcers, deep abscesses, and 
soft yellowish vegetations which have undergone partial 
necrosis. Microscopic examination reveals myriads of 
micro-organisms. 

Symptoms. — They are divided into three classes: Gen- 
eral, cardiac, and embolic. 

General Symptoms. — There is a high and irregular 
fever, repeated chills, profuse sweats, great prostration, 
often delirium and stupor, hurried breathing, a rapid 
irregular pulse, and a brown, fissured tongue. Jaundice 
and diarrhea are frequently present. 

Cardiac Symptoms. — Precordial pain, palpitation, and 
often murmurs at one or more valves. These may be 
absent. 

An embolism is a small portion of the vegetation 
formed on the valve leaflets which becomes loosened and 
is swept into the circulation by the force of the blood 
current. It is carried through the arterial system until it 
lodges in a vessel of too small caliber to permit its passage. 
In this position it entirely plugs up the artery and prevents 
the passage of blood. This causes the part supplied by 
the arteries to be cut off from its blood-supply. 

Peripheral emboli yield a petechial rash; renal em- 
boHsm may yield a bloody urine, splenic embolism may 
yield a painful spleen; cerebral embohsm may yield 
paralysis. The disease lasts from a few days to five or 
six weeks. Death almost invariably results. 



DISEASES OF THE CIRCULATORY SYSTEM 1 8/ 

MYOCARDITIS 

Acute myocarditis is an acute inflammation of the 
heart muscle. It is rare in childhood. It is almost always 
secondary to endocarditis or pericarditis. As a primary 
affection of the heart it may be due to rheumatism or to 
one of the infectious fevers. The heart muscle becomes 
degenerated, flabby, and friable. 

The symptoms are those characteristic of any heart 
condition, and include pain, dyspnea, a very rapid and 
irregular pulse, and since the heart muscle itself is v^eak- 
ened, the heart -beats are weak and, in addition, the pulse 
very small. 

Fibroid heart is the term given to a chronic myocarditis; 
it is characterized by an overgrowth of connective tissue, 
just as in any chronic inflammation elsewhere. 

HYPERTROPHY OF THE HEART 

Hypertrophy of the heart is an enlargement of the 
heart due to an overgrowth of its muscle. It is caused 
by increased work, and this may be due to too much blood 
to be removed from the heart, as in regurgitant valvular 
lesions ; obstruction to the outflow of the blood at the 
valves, as in the stenoses or obstruction in the pulmonary 
or systemic circulation, as in emphysema or Bright 's dis- 
ease; resistance to ventricular contraction, as in adhe- 
sions; undue physical exertions, long continued. 

Varieties. — Simple hypertrophy comprises a thickened 
muscle with a normal cavity. Eccentric hypertrophy 
(hypertrophy with dilatation) consists of a thickened 
muscle and dilated cavities. 

Concentric Hypertrophy. — There is a thickened muscle 
and the cavities are diminished in size (always congenital). 



1 88 DISEASES OF CHILDREN FOR NURSES 

Dilatation of the heart is an enlargement of the heart 
due to the stretching of its walls. 

Varieties. — Dilatation with thickening of the walls, 
which is the same as eccentric hypertrophy; dilatation 
with thinning of the walls. 

Dilatation results from excessive pressure within the 
chambers of the heart, as from sudden extreme exertion; 
in valvular disease; and in impaired nutrition of the heart 
muscle, as in low fevers, valvular disease and sclerosis, 
or hardening of the arteries of the heart. One or both 
ventricles may be dilated, but usually the right. 

Symptoms. — As long as the associated hypertrophy 
keeps pace with the dilatation there are no symptoms, but 
when the dilatation preponderates, the following symptoms 
of venous stasis appear: Dyspnea and cough, the blood 
being dammed back in the venous system causes en- 
gorgement of the lungs; scanty urine from congestion of 
the kidneys; dyspepsia from congestion of the stomach. 
There is general dropsy, and feeble, irregular pulse. 

Fatty degeneration of the heart is a changing of the 
heart muscle into fat. When fat is merely deposited upon 
the heart muscle it is termed fatty infdtration. Fatty 
degeneration is due to sclerosis of the coronary arteries, 
valvular diseases, infectious fevers, and to certain poisons, 
as arsenic, phosphorus, and antimony. 

Symptoms are those of heart failure: Dyspnea, asthma, 
cough, weak, irregular pulse, poor digestion, dropsy, 
syncope, and Cheyne-Stokes respiration. 

NURSING OF CARDIAC DISEASES 

Absolute rest is of the greatest importance; light and 
nutritious diet, improvement of the general condition by 



DISEASES OF THE CIRCULATORY SYSTEM 1 89 

careful hygienic surroundings. Ice to the precordia will 
frequently relieve pain. 

Bathing should be accomplished only by sponge baths. 

In a severe case of heart disease the child should lie on 
its back without a pillow. When dyspnea is marked it is 
necessary to prop up the child in bed so that it can breathe 
with less discomfort (orthopnea). 




X::" 



Fig. 49 — Position in orthopnea. The baby is supported by a frame, a pillow is 
placed on both sides to support elbows, and a folded sheet is passed around feet to pre- 
vent child from slipping down. The sheet is held in position by bandages attached 
to head of bed. 

The temperature, pulse, and respirations should be 
taken at least twice a day. It may be necessary to take 
the pulse more often, and in severe cases the pulse should 
be under constant observation. 

Symptoms of heart failure demand instant attention. 
Whenever the pulse becomes rapid, intermittent, and weak, 
or the child has sudden attacks of dyspnea, coldness of the 
extremities, or attacks of syncope, the physician should be 
immediately informed. While awaiting his arrival the 



IQO DISEASES OF CHILDREN FOR NURSES 

child should be placed flat upon its back and not moved 
for anything. Mustard paste, made of equal parts of 
m_ustard and flour, may be applied to front of chest until 
there is a distinct redness, 15 minims of aromatic spirits 
of ammonia may be given in water by the mouth, if the 
child can swallow; hot-water bags may be placed about 
the extremities, and inhalations of ammonia given. (Be 
careful not to have concentrated ammonia nor to hold it 
continuously under the nose; pass it slowly backward and 
forward.) The physician will probably order a hypoder- 
mic injection of one of the following drugs : nitroglycerin, 
strychnin, digitalis, or whisky, all of which should be in 
readiness. Hypodermoclysis may be ordered and at times 
he may bleed the child. 

DISEASES OF THE BLOOD-VESSELS AND THE BLOOD 

Aneurism is a circumscribed dilatation of an artery. 
It is uncommon in childhood. The cases reported have 
been due to hereditary syphiHs. 

The arch of the aorta is the most frequent seat; there 
may be abdominal aneurisms, and also aneurisms of any 
artery of the body. 

Symptoms. — Thoracic aneurisms: Dyspnea, metallic 
cough, pain, difficulty in swallowing, dilatation of super- 
ficial veins, unilateral sweating, paralysis of the sympa- 
thetic nerves, and the presence of a tumor. 

Arteriosclerosis is a thickening of the arteries due to 
an overgrowth of connective tissue, associated with more 
or less fatty degeneration and hardening. Not common 
in childhood. 



DISEASES OF THE CIRCULATORY SYSTEM I9I 

BLOOD 

In health the blood amounts to about one-thirteenth of 
the body-weight. It is composed of serum (a watery 
fluid), red blood-corpuscles, and white blood-corpuscles. 

Hemoglobin is the coloring matter of the red blood- 
corpuscles ; it is principally composed of iron. Its function 
is to carry oxygen to the tissues of the body. 

Estimation of the Red and White Corpuscles. — The 
number is obtained by accurate mathematical calculation. 
The instrument used is called a hemocytometez. 

The blood withdrawn into the capillary tube is accurately 
diluted and a drop of this is placed upon a measured glass 
slide of known dimensions. Under the microscope the 
number of red and white corpuscles is counted in the 
measured area. The dilutions being known, the number 
of corpuscles in a cubic milHmeter can be deduced. 

The hemoglobin is estimated by means of an instrument 
called a hemoglohinometer. 

There is a prism of colored glass so arranged that one- 
half of a small circular receptacle stands above it, con- 
taining clear water. The other half contains diluted 
blood. By means of a reflected light and the movable 
prism, which is graded from a Hght to a deep reddish hue, 
the two sides are so adjusted that they will be of the same 
shade. The percentage is read from a small scale attached 
to the shding prism. Normal blood will read 100 per cent, 
on this instrument. 

The specific gravity of the blood is obtained by 
placing a drop of blood in a fluid mixture of known 
specific gravity. When the drop remains stationary the 
specific gravity is the same as the mixture. 



192 



DISEASES OF CHILDREN FOR NURSES 



Blood-pressure. — This is taken by means of an 
apparatus (a sphygmomanometer) which registers in 
milHmeters of mercury the amount of pressure that is 
present in the arteries during (i) the passage of the pulse 
wave (systoHc pressure), (2) the actual pressure in the 
arteries during diastole (diastolic pressure). 

A rubber bag contained in an arm band is placed about 
the arm above the elbow and air is pumped into this bag 
until the pressure is sufhcient to compress the artery at 
that point. This, of course, stops the pulse. The air 




Fig. 50. — Rogers' sphygmomanometer (Morrow). 

is then allowed to escape until the pulse can be felt at 
the wrist or heard through the stethoscope placed over 
the brachial artery below the encircling band. At this 
point the systolic pressure is read off. The diastolic 
pressure is obtained by allowing the air to escape until 
the pulsations are no longer audible through the stetho- 
scope ; at the point where the sound ceases we read off the 
diastolic pressure. 

The difference between the two readings is called the 
pulse pressure. 

The normal pressure varies with the age. From three 



DISEASES OF THE CIRCULATORY SYSTEM 1 93 

to thirteen the normal systolic pressure is fairly con- 
stant between 90 and 103 m.m. At the age of puberty 
it rises rather rapidly toward the adult figures, which 
normally should be between 115 and 130 m.m. 

In infants under three years of age it is impracticable 
to take blood-pressure. 

Normal blood contains 5,000,000 red blood corpuscles 
to a cubic millimeter. 

At birth there are about 18,000, and later in childhood 
from 6,000 to 12,000 white blood-corpuscles to a cubic 
millimeter. The specific gravity is about 1.055. 



^ 


"l 


rr^ 










i 






















j 










'1 










I 






1 




u 






1 


























s 




1 


7 


V 


J^^ 


LU 


y 




Fig. si. — Thoma-Zeiss hemocytometer : a, Slide used in counting; i, sectional view; 
c, portion of ruled bottom of well ; d, red pipet ; e, white pipet. 

Anemia is a condition of the blood in which it is de- 
ficient in quantity or in one or more of its constituents. 

It is evidenced by pallor of the skin and mucous mem- 
brane, and by progressive weakness. Iron is used as the 
remedy, its action tending to increase the percentage of 
iron in the depleted hemoglobin. 
13 



194 DISEASES OF CHILDREN FOR NURSES 

Pernicious anemia is a grave form of anemia character- 
ized by a great deficiency in the number of red blood- 
corpuscles, and not associated with any definite causal 
lesion. 

Plethora is an increase in the whole quantity of blood. 

Leukocytosis is an increase in the number of white 
blood-corpuscles. 

Leukemia is a disease characterized by a great increase 
in the number of white blood-corpuscles, with lesions of 
the spleen, lymphatic glands, and bone-marrow. 

Chlorosis is a disease in which there is a great reduction 
in the hemoglobin (coloring matter), without any decrease 
in the red blood-corpuscles. It derives its name from the 
green tint of the skin. 

Von Jaksch's disease is characterized by a decrease 
in the red blood-corpuscles and hemoglobin, and by 
marked leukocytosis with enlargement of the spleen and 
at times the liver. 

HEMOPHILIA OR BLEEDER^S DISEASE 

This is an hereditary disease characterized by a tendency 
to bleed excessively from slight wounds or spontaneously. 
It is probably the worst condition with which a surgeon 
can be confronted. Children afflicted can bleed to death 
from a pin scratch, nothing apparently being of use to 
stop the hemorrhage. It usually runs in families, several 
brothers being affected; the sisters, however, are generally 
immune. ' 

Symptoms. — The symptoms are free and persistent 
hemorrhage after a trivial injury. Spontaneous hemor- 
rhages from mucous membranes of the nose, stomach, 
and bowel, and subcutaneous extravasations of blood 
are common. 



DISEASES OF THE CIRCULATORY SYSTEM ig^ 

Treatment consists in ligation, application of styptics, 
and plugging of the nose in epistaxis. 

PURPURA 

This condition is characterized by extravasations of 
blood into the skin. When there is likewise hemor- 
rhage from the mucous membranes it is spoken of as 
purpura hemorrhagica. 

Purpura occurs in quite a variety of conditions. It is 
seen in malignant cases of endocarditis, in severe cases of 
measles, scarlet fever, variolai and vaccinia, also in epi- 
demic cerebrospinal meningitis and occasionally in diph- 
theria, rheumatism, pyemia, and septicemia. 

Purpura also occurs late in the course of many of the 
protracted diseases, especially in infancy, such as broncho- 
pneumonia, empyema, tuberculosis, enterocolitis, menin- 
gitis, and malignant cases. 

Certain drugs, .such as- phosphorus, quinin, and potas- 
sium chlorate, may produce purpura when long continued. 

Primary cases of purpura, not associated with any of the 
previously mentioned causes, occur in children of all ages, 
being not uncommon in infancy. 

Symptoms. — The onset may be marked by some fever, 
headache, malaise, and pain in the limbs, but these may 
be absent and the disease ushered in by copious crops of 
small hemorrhages in the skin, followed by bleeding from 
the mucous membrane. Anemia and its associated phe- 
nomena develop in severe cases. 

There may also be hemorrhages from the bowel, kidneys, 
and stomach. 

It occurs at times in connection with rheumatism, when 
hemorrhages into the joints are seen, especially the knee- 



196 DISEASES OF CHILDREN FOR NURSES 

and ankle-joints. In the most severe forms gangrene of 
the mucous membranes involved is sometimes observed. 

All forms of purpura have a tendency to relapse. 

Prognosis. — The appearance of purpuric spots during 
the course of an infectious disease is always a bad sign, as it 
usually denotes a very severe infection. In the cachectic 
varieties it usually heralds the approach of death. Prim- 
ary cases of purpura simplex generally recover. Primary 
cases of purpura hemorrhagica usually recover unless the 
fever is marked. The gangrenous form is fatal. 



CHAPTER IX 
NERVOUS DISEASES 

ANATOMY OF THE NERVOUS SYSTEM 

The central nervous system is composed of the brain, 
the spinal cord, and their coverings. 

The brain is contained within the cavity of the skull. 
It is the center of thought, of the perception of the five 
senses, and of the voluntary motor activities of the body. 




Fig. 52^ — Functional areas of the cerebral cortex, left hemisphere (A. A. Stevens). 

The brain or cerehriim is divided into the right and 
left hemispheres by the median fissure. The two hemis- 
pheres are united by fibers running through the corpus 

callosum. 

197 



198 



DISEASES OF CHILDREN FOR NURSES 



The lower portion is divided into the cerebellum, the 

crura, the pons, and the medulla. 

The brain is composed of gray 
and white matter, the gray matter 
being external and about a half 
inch in thickness; it is called the 
cortex. The rest of the brain is 
made up principally of white matter 
and consists of nerve fibers running 
in various directions. 

The cortex presents upon its 
surface deep grooves, which are 
called fissures or sulci. These 
fissures are numerous and divide 
the brain into convolutions. This 
arrangement gives the greatest 
area of cortex in the smallest 
amount of space. The more de- 
veloped the convolutions, the greater 
the intellect of the individual. 
The fissures also divide the brain 
into different lobes, such as the 
frontal, temporal, and parietal 
lobes. 

The fissure of Sylvius is a large 
sulcus on the external lateral sur- 
face of the brain, and it receives 
a portion of the wing of the sphe- 
noid bone. 

The fissure of Rolando runs from 
the center of the vault of the 
skull, downward and forward toward the ear, Aiound 




Fig. S3- — General view of the 
cerebrospinal nervous system (after 
Bourgery ; Schwalbe). 



NERVOUS DISEASES 1 99 

this fissure are located the motor centers of the body; 
that is, the nerve cells which form the nervous im- 
pulses, making voluntary motion possible. 

The arrangement of the motor centers is ''upside down"; 
that is, the center for the legs is uppermost; then, in order, 
the center for the trunk, the arms, the face, and head, the 
last-named being the lowest in location. (See Fig. 52). 

The nerve fihers run from the centers around the fissure 
of Rolando, through the internal capsule (a pathway 
in the substance of the brain), to the crura. A hemor- 
rhage within the internal capsule is the cause of hemi- 
plegia. The blood-clot, by exerting pressure, prevents 
any passage of nervous impulses, producing paralysis of 
the muscles suppHed. 

The crura are two extensions of the brain, one from 
each hemisphere, which carry motor and sensory fibers. 
They unite and carry the fibers from both hemispheres 
as far as the pons. 

The pons is a bridge of nervous tissues. It not only 
contains the motor and sensory fibers from the cortex — 
carrying them from the crura to the medulla, the next 
portion of the nervous system below — but it also contains 
fibers running between the two hemispheres of the cere- 
bellum. 

The medulla or hulh is the lowest portion of the brain, 
and at the foramen magnum it becomes the spinal cord. 
The motor and sensory fibers decussate or cross from one 
side to the other in the medulla. On account of this 
crossing of fibers an injury to the left side of the brain 
produces a paralysis of the right side of the body (hemi- 
plegia). The medulla contains the center of the involun- 
tary movements, as respirations, etc. 



200 DISEASES OF CHILDREN FOR NURSES 

The motor -fibers run through the anterior and lateral 
columns of the spinal cord and the sensory fibers through 
the posterior columns. At the level of the muscle to be 
supplied the motor fiber leaves the cord by one of the 
spinal nerves and runs through the branch of this nerve 
to the muscle. The sensory fibers run from the skin 
surface and return to the cord through the spinal nerve 
and enter the posterior columns of the cord. 

In the cerebellum is located the center of co-ordination. 
These centers keep all portions of the body working 
together in unison. 

The basal ganglia are isolated areas of gray matter 
within the white matter of the brain, and are associated 
with the special senses. 

The ventricles of the brain are cavities within its sub- 
stance. There are four in number, all connected and 
containing cerebrospinal fluid. 

The spinal cord is contained within the spinal column 
and is a continuation of the medulla. The pathways of 
the motor and sensory fibers are external, the gray matter 
being located in the center in the form of an H. 

The cord is divided into columns. The posterior column 
receives the sensory filaments through which they run on 
their way to the brain. 

The lateral columns and the anterior columns are com- 
posed of motor filaments running from the brain to the 
muscle. 

The central area of gray matter contains trophic cells 
in addition to motor fibers. 

Trophic cells supply the tissues with proper nervous 
tone; when they are injured bed-sores develop and atrophy 
of the muscles occurs. 



NERVOUS DISEASES 



20 1 



The spinal cord contains most of the centers of reflex 
action. 

Since the posterior columns carry only sensory fibers, 
injury or disease of this part of the cord will cause a loss 
of sensation below the lesion {locomotor ataxia). 

Since the anterior and lateral columns carry only motor 
fibers, injury or disease of this part of the cord will cause 
paralysis below the lesion {myelitis). 




Fig. S4- — Lumbar section of spinal cord showing main tracts of white substance 
and location of principal groups of nerve-ceils in gray matter: a. Anterior median fissure; 
b, posterior median fissure; c, anterior horn of gray matter; d, posterior horn of gray 
matter; e, central canal; /, anterior white commissure; g, posterior white commissure; 
h, i, anterior and posterior gray commissures; /, anterior median column; K, lateral column; 
L, posterior column; m, column of Clarke; n, inner group of nerve-cells; o, anterior group; 
p, anterolateral group; q, posterolateral group; r, lateral horn (Leroy). 



The Meninges. — The brain and spinal cord are cov- 
ered by three membranes: the dura, the arachnoid, and 
the pia. 

The dura is a thick, fibrous structure lining the cavities 
of the skull and spinal canal, dipping into the median 
fissure and separating the cerebellum from the cerebrum. 
Tt also forms the venous sinuses of the brain and surrounds 



202 DISEASES OF CHILDREN FOR NURSES 

the cranial nerves. The function of the dura is to act 
as a protection to the structure enclosed. 

The arachnoid is a serous membrane and is very 
similar to the pleura and the pericardium. It surrounds 
the brain and cord, and is reflected so that there are 
tv70 surfaces betw^een which there is a closed sack, con- 
taining the cerebrospinal fluid. The sack is continuous 
with the ventricles of the brain. This arrangement not 
only lubricates the slight movements of the cord and the 
brain, but permits the central nervous system to rest on a 
cushion of water, which annuls many shocks. 

The pia is a thin mesh work of blood-vessels. It closely 
surrounds the brain and the spinal cord, dipping into 
the fissures and ventricles, and is the main blood-supply 
of the cortex and cord. 

The cranial nerves are twelve in number: (i) olfac- 
tory, (2) optic, (3) motor oculi, (4) pathetic, (5) trifacial, 
(6) abducens, (7) facial, (8) auditory, (9) glossopharyn- 
geal, (10) pneumogastric, (11) spinal accessory, (12) 
hypoglossal. 

They supply the organs of the special senses, the 
structures of the face, the head and the neck, and, through 
the pneumogastric, the lungs, the heart, and the stomach. 

The spinal nerves consist of thirty-one pairs. They 
leave the spinal cord at various levels and carry motor 
fibers to, and sensory fibers from, the trunk and the upper 
and lower extremities. The nerves supplying the various 
structures of the above parts of the body are branches 
of the spinal nerves. 

The sympathetic nerves control involuntary actions 
and keep the different parts of the body working smoothly 
together (co-ordination). 



NERVOUS DISEASES 203 



TERMINOLOGY 



The disturbances of motion are paralysis^ convulsions^ 
choreijorm movements^ and tremors. 

Paralysis may involve one member only, and it is then 
termed monoplegia; a lateral half of the body, when it is 
termed hemiplegia; or it may involve the body from the 
waist down, when it is called paraplegia. 

A convulsion is a condition in which there are excessive 
muscular contractions, continued or intermittent, depen- 
dent upon the involuntary discharge of the motor impulses 
from the nerve centers. 

Intermittent contractions are termed clonic; continued 
contractions, tonic. Convulsions may be general or 
local. The term spasm is sometimes applied to the 
latter. 

Varieties of convulsions: Epileptiform, tetanic, and 
hysteroidal. 

Epileptiform convulsions are characterized by uncon- 
ciousness, and for the most part the movements are clonic. 
They are preceded by an aura, and the patients bite 
their tongues. 

Tetanic Convulsions. — In this form the discharges 
emanate from the spinal cord and the convulsive move- 
ments are continuous and not associated with uncon- 
ciousness. 

Hysteroidal convulsions are manifestations of hysteria, 
and in them consciousness is only partially or apparently 
lost. They are not preceded by an aura, but sometimes 
by a sensation as of a ball in the throat. The eyes are 
partially closed, the face expresses some emotion, the 
tongue is not bitten, the movements are tonic, or, if clonic, 



204 DISEASES OF CHILDREN FOR NURSES 

appear wilful. The paroxysm is of long duration and the 
patient frequently weeps or laughs. 

There are various local spasms, such as hiccough, 
croup, and laryngismus stridulus, etc. 

Choreiform movements are coarse, jerky, irregular, 
involuntary movements, which more or less simulate 
purposeful movements. 

Athetosis is the term applied to certain movements of 
the hands and feet in which there is a slow, twisting, 
interwinding, separation and extension of the fingers and 
toes. It is frequently observed in the cerebral palsies of 
children. 

Tremors are fine, vibratory movements due to the 
alternate contraction and relaxation of antagonistic groups 
of muscles. 

The knee-jerk is obtained by tapping the quadriceps 
tendon between its insertion and the patella while the 
legs are crossed. The value of the knee-jerk depends 
upon the mechanism of its production. This is called 
the refex arc. It consists of the sensory nerve running 
from the patella tendon to the spinal cord, where it enters 
the reflex center. From this center the motor nerve runs 
to the muscle, causing it to contract. If the arc is broken 
by disease or injury to any one of its parts the knee-jerk 
is lost. When there is any irritating lesion of the cord 
the reflexes are increased. When there is any destructive 
lesion of the cord the arc is broken and the knee-jerks 
are absent. They are, therefore, a very important 
diagnostic symptom. 

Ankle clonus consists in a vibratory movement 
obtained by supporting the tendo AchiUis with one hand 
while the foot is strongly flexed. 



NERVOUS DISEASES 205 

Babinski*s reflex is obtained by tickling the sole of 
the foot; if there is an injury or disease of the central 
nervous system the great toe will move upward instead of 
downward, as it does normally. 

Sensation. — Anesthesia means loss of sensation. 

Hyperesthesia means exaggerated sensation. 

Paresthesia is used to indicate certain disagreeable 
sensations, such as numbness, tingling, itching, creeping, 
and feeling of '^pins and needles." 

Arthropathies are degenerative changes of the joints. 

Coma is a condition of unconsciousness from which the 
patient cannot be aroused. 

Temporary unconsciousness due to anemia of the brain 
is termed syncope. 

Catalepsy is characterized by a peculiar stiffness of 
the muscles, and when this is overcome by force, the 
limbs can be placed in unnatural positions, which they 
retain for a long time. There may or may not be a loss 
of consciousness and sensation. 

PECULIARITIES OF DISEASE OF THE NERVOUS 
SYSTEM IN CHILDREN 

Owing to the immature development of the central 
nervous system, and to the great irritability of the per- 
ipheral or terminal sensory nerves, much more serious 
nervous symptoms are shown by children from trivial 
causes than are seen in adult life. Hence, conditions 
such as convulsions, tetany, St. Vitus' dance, and enuresis 
are common. 

The greatest factors in the cause of such conditions are 
stimulants, such as tea and coffee, and the fact that chil- 
dren live among exciting surroundings. Plenty of sleep 



2o6 



DISEASES OE CHILDREN EOR NURSES 



and quiet are essential to the proper development of 
the nervous system. The effects of such conditions as 
infantile paralysis and birth palsies last through life. 

Hemorrhage of the brain is usually cortical, on the 
outside of the hemisphere, and not v^ithin its substance. 




Fig. 55- — Spina bifida (Eisendrath). 

Malformations. — Meningocele is a protrusion of the 
covering of the brain (meninges) through some abnormal 
opening in the skull or spinal canal. It contains cerebro- 
spinal fluid. When they are spinal in origin they are 
spoken of as spina bifida. 

Encephalocele is a protrusion of a portion of the meningus 
containing brain substance. 

Hydro-encephalocele contains both brain substance 
and fluid. 

Microcephalus is a name given to a small head due to 
under-development. 



NERVOUS DISEASES 20/ 

Hydrocephalus is an enlargement of the skull due to a 
large amount of cerebrospinal fluid within the ventricles. 

Other deformities are noted, such as absence of a 
whole or a part of the brain. 

Diseases of the Meninges 
MENINGITIS 

This term is applied to any inflammation of the mem- 
branes covering the brain and spinal cord. It may be acute 
or chronic, and occurs (i) as a complication of the infec- 
tious diseases, (2) following some local cause, and (3) 
epidemically. 

The epidemic variety is also spoken of as epidemic cere- 
brospinal meningitis or spotted fever, and is described on 
page 267. 

When the membranes covering the brain are involved 
it is called cerebral meningitis; when the spinal cord is the 
seat of the disease it is spinal meningitis; more often both 
the brain and spinal meninges are involved, and it is then 
spoken of as cerebrospinal meningitis. 

Pathology. — The membranes are serous in character, 
they surround the cranial nerves as they leave the brain, 
and the spinal nerves as they emerge from the cord. 

When a serous membrane is diseased it first becomes 
very red and inflamed, and later there is an exudate. 

The first stage produces intense irritation of all the sur- 
rounding tissues, hence in cerebral meningitis there is 
severe headache and involvement of the nerves of the spe- 
cial senses. This causes intolerance of sound and light. 
Later, when the exudate develops, it produces pressure, 
and instead of irritation there is paralysis of those parts 
supplied by the nerves subject to the pressure of the exu- 



208 DISEASES OF CHILDREN FOR NURSES 

date. Deafness and blindness are then found instead of 
the symptoms of irritation. 

In spinal meningitis, at first, there is present a spas- 
modic condition of the muscles due to the irritation of the 
spinal nerves, this is followed, after the exudate develops, 
by paralysis due to the pressure. When both the cerebral 
and spinal meninges are involved we have a combination 
of the above symptoms. Acute meningitis is most often 
caused by the diplococcus of pneumonia, by infection from 
a suppurating wound, by the bacilli of the infectious 
fevers, by traumatism, and especially by the tubercle 
bacillus. 

The prognosis of all forms of meningitis is very grave. 
The non-tubercular varieties occasionally recover. Tuber- 
cular meningitis is invariably fatal. In the epidemic 
variety, Flexner's serum has given wonderful results. 

The picture of a case of meningitis is complete in the 
tubercular variety, and only that form will be given here. 

Tubercular meningitis (cerebral) is an acute inflam- 
mation of the cerebral meninges excited by the tubercle 
bacillus. 

In children the disease may be primary or secondary to 
a focus of tuberculosis in some other part of the body. 
The majority of cases are seen between the second and 
fifth year. 

The basilar meninges covering the lower part of the 
brain are especially involved. The pons, crura, and 
medulla are covered with lymph which mats together in 
a common mass the adjacent nerves and blood-vessels. 
The fluid within the ventricles of the brain is increased. 

Symptoms. — The disease usually begins insidiously 
with dulness and irritability on the part of the child. 



NERVOUS DISEASES 



209 



Sleep is disturbed. The child twitches, grinds its teeth, 
and starts up with a cry of alarm. When the disease is 




Fig. 56. — Kemig's sign. The thigh is held at right angles to the body. When an 
attempt is made to extend the leg, bringing it into a line with the thigh, there is either 
marked resistance or an inability to extend the leg, if meningitis is present (Kerr). 

fully developed headache is intense and causes a shrill 
scream, known as the hydrocephalic cry. The special 
senses are extremely acute, bright lights and noises cannot 
be tolerated; the child becomes irritable when touched. 
The temperature ranges between 102° F. and 103° F. 
The pulse is rapid at first, but later is slow and irregular. 
The walls of the abdomen are flat. The child lies on 
its side with the Hmbs drawn up, the head is bent far back, 
the fingers are clenched over the thumbs which are turned 
into the palm of the hand. This is called opisthotonos. 
Convulsions are common and may be local or general. 
Toward the close of the stage the child becomes delirious. 
When the exudate is of sufficient' amount to exert pressure, 
paralysis develops, especially in the muscles of the face. 
Coma follows the delirium, the eyes are rolled up, and 
14 



2IO 



DISEASES OF CHILDREN FOR NURSES 



blindness and deafness result. If the finger is drawn 
across the body a bright red line develops and remains 




Fig. 57. — Method of introducing needle in lumbar puncture: Child in lying posture 

(Boston). 

for some moments; this is called a tache. In the last stage 
the pulse becomes weak, rapid, and irregular; respirations 
assume the Cheyne-Stokes characteristics, and the tem- 
perature falls. The duration is from one to three weeks. 
Kernig^s Sign. — The inabihty to straighten out the leg 
when the thigh is bent upon the abdomen. It is present 
in cases of cerebral meningitis. 

Lumbar Puncture. — During the course of the disease the 
physician may find it necessary to relieve the tension in the 
spinal canal, or he may desire to obtain fluid for diag- 
nostic purposes. He then will tap the spinal canal by the 
lumbar puncture method. In preparing for this pro- 
cedure the skin over the lumbar portion of the spine must 
be scrupulously sterilized and every aseptic precaution 
must be absolute. The child is usually held in the posi- 
tion as shown in Fig. 5 7 . The method consists in inserting a 
long hypodermic needle between the vertebrae and through 



NERVOUS DISEASES 211 

the membrane; as soon as it enters the spinal canal the 
cerebrospinal fluid runs out of the needle. Several sterile 
test-tubes should be in readiness to catch the fluid. When 
they are filled, plug them with aseptic cotton. The wound 
in the skin is usually closed with adhesive plaster or a 
collodion dressing. 

Diseases of the Brain 

In diseases of the brain the centers for the various 
functions, such as motion, sensation, speech, hearing, 
seeing, smelHng, and hearing, are interfered with. The 
pathways leading from the centers may be involved as they 
traverse the brain on their way to the spinal cord. 

Diseases of the brain are usually diagnosed by what are 
termed pressure symptoms^ produced by clots, tumors, 
abscesses, cysts, etc. 

The minute anatomy of the brain is almost as well 
known as that of the spinal cord. The brain centers 
are definitely located and the direction of the pathways 
of the fibers from these centers is known. Therefore, 
it is possible to locate accurately a lesion of the brain, 
either a tumor, cyst, abscess, or morbid growth, from 
the pressure-symptoms which they produce. Areas of 
sclerosis and hemorrhage, destroying or impairing the 
centers and nerves or the tracts from the centers are 
determined in the same manner. 

A lesion in a definite part of the brain will involve certain 
centers and nerves which will produce paralysis of the 
parts suppHed by those nerves. Thus, if there is a hemor- 
rhage or a tumor pressing on what is known as Broca's 
area in the brain, which is the speech center, there will be 
impairment or loss of the function of speech. If this 



212 DISEASES OF CHILDREN FOR NURSES 

symptom is present with other symptoms of cerebral 
involvement, such as persistant headache or unconscious- 
ness, choked disk (a condition of the eye), and paralysis 
of other parts of the body, there is a tumor involving 
Broca's area. 

A more accurate diagnosis than this can be made. The 
position of the motor areas around the fissures of Rolando 
are ''upside down," the leg area above, the arm in the 
center, and the face below. The first symptoms of irri- 
tation to nervous structures are convulsions. Convulsions 
due to brain irritation of the motor areas are characteristic. 
They begin in the part that corresponds to that portion 
of the brain which is irritated. If the irritation is in the 
hand area of the motor region the convulsion will start 
in the hand, gradually extend up the arm, and then become 
general. This form of convulsion is termed Jacksonian 
epilepsy. A finer distinction than locating the lesion in 
the hand area can be made. If the positions in the 
different areas in the motor region are known, by watching 
this convulsion which starts in the hand, and by noting 
what parts are successively involved, the extent and 
direction of the convulsion can be determined. If, after 
the convulsive movements reach the shoulder, they 
involve the corner of the mouth it is plain that the lesion 
in the brain extends downward. If, on the other hand, 
the leg is the next part to become involved the lesion 
extends upward. This will impress the nurse with the 
necessity of observing a convulsion carefully so that the 
diagnosis can be accurately made, for brain surgery 
demands accuracy, and as so many lesions of the brain 
can be treated only by surgical means, its importance can 
be appreciated. 



NERVOUS DISEASES 213 

A nurse will be able to observe convulsions more closely 
than anybody else; therefore, she should note the kind of 
convulsion, whether tonic or clonic, where it begins, what 
parts are successively involved, in which direction the 
eyes and head turn, for in destructive lesions the head 
and eyes are usually turned toward the side of the lesion 
of the brain, and in irritating lesions to the opposite side. 
Also note what parts of the face are involved, as the nerves 
supplying the face emerge from the skull at different levels. 
A lesion at one level might involve a nerve after it had 
crossed, giving a paralysis on the same side as the lesion 
instead of the opposite, as is the rule, producing the so- 
called crossed paralysis; while at another level it may be 
affected before it has decussated, giving a paralysis on 
the opposite side of the face. This knowledge gives aid 
in the determination of the level of the lesion. Also note 
whether the eyehds are drooped and whether the patient 
is conscious or unconscious. 

CONVULSIONS 

Convulsions occur frequently in childhood. They are 
due to direct irritation of the cortex or to reflex irritation. 
The poisons generated by the acute infectious diseases 
may so irritate the cortex that convulsions occur during 
the course of these diseases. Convulsions often usher 
in an attack of illness in children. 

Reflexly, indigestion, teething, and other trivial causes 
at times produce general convulsions. This is due to the 
instabihty of the nervous system at this early stage. 

Treatment. — A mustard tub, temperature 110° F., for 
five minutes is the best method to employ (see page 
440) . The tongue should be protected by inserting some- 
thing between the teeth and an enema given immediately. 



214 DISEASES OF CHILDREN FOR NURSES 

CEREBRAL PARALYSIS 

Birth palsy in children is not uncommon. It is caused 
by a hemorrhage upon the cortex of the brain, rarely 
within the brain substance. The hemorrhage usually 
occurs during the birth of the child. 

The resulting paralysis may be a hemiplegia, half 
of the body being involved. Contractures occur and the 
children are usually mentally deficient and crippled. 




Fig. 58. — Hydrocephalus (side view) (Kerr). 

Cerebral paralysis may occur after birth, in which case 
the same symptoms are found. 

Erb's paralysis is a form of birth paralysis not due to a 
hemorrhage of the brain. It affects the upper portion of 
the arm, and is due to an injury around the shoulder- joint 
during birth. 



NERVOUS DISEASES 



215 



Apoplexy IS the term applied to a hemorrhage in the brain. 

Thrombosis of the sinuses of the dura occurs at times, 
most frequently after an operation upon the mastoid cells. 

Abscess and tumors are rare in childhood. They 
cause pressure symptoms. The most common tumors are 
tubercular in character. 




Fig. sg. — Sporadic cretin: before treatment. (From Osier, Sporadic Cretinism in 

America). 

Hydrocephalus is a condition in which there is excessive 
fluid in the ventricles or in the arachnoid cavities. It 
gives to the head a peculiar shape. It is large and round, 
the sutures and fontanels are enlarged, the convolutions 
of the brain are flattened, and usually there is imbecility. 

Cretinism is a congenital affection characterized by a 
lack of physical development due to an abnormal condition 
of the thyroid gland. The symptoms are myxedema 
(a v^axy condition of the subcutaneous tissues), an ab- 
normally large tongue, and idiocy or imbecility. 



2l6 DISEASES OF CHILDREN FOR NURSES 

The administration of thyroid gland extract to these 
cases causes a remarkable improvement. 

Achondroplasia, Chondrodystrophy. — Achondroplasia 
has been known under the synonyms of ''chondrodys- 
trophia fetalis," ''fetal rickets/' "fetal cretinism," and 
"micromelia." Sommering first described it in 1791. 
Achondroplasia is of great antiquity. Parnet draws 
attention to the fact that at the British Museum there 
are a number of glazed earthenware images which are 
unquestionably models of achondroplastic individuals. 
They were represented as dwarfs, with big heads, crooked 
legs, very long arms, etc. It is congenital. 

These children are dwarfs and there is marked short- 
ening and bowing of the upper and lower extremities. 
The spine is also curved. There is prominence of the 
lower jaw and a "pug-nose"; a peculiar separation of the 
fingers, called the trident hand, and prominent abdomen. 
They have normal intellect. 

Deaf-mutism is due to congenital or early loss of 
hearing. As the child has never heard spoken words he 
is unable to imitate the proper sounds. It may also 
develop in children who have begun to talk, but in whom 
the deafness occurs at such an early age that they soon 
lose the memory of what they have accomplished. 

Congenital myotonia (spasmodic affections) is an 
affection of the muscles in which a spasmodic rigidity is 
observed when the child brings them into action after 
repose. It lasts for a few moments and may recur when 
volimtary movements are again attempted. It is in- 
curable, but tends to improve with muscular exercise. 

Aphasia is a failure of word memory, an inability to 
utter words, to comprehend them, or to write them. 



NERVOUS DISEASES 



217 




-The "trident hands" in achondroplasia (Fussell, McCombs, deSchweinitz, 
and Pancoast). 




Fig. 61. — Achondroplasia. Side view of boy. Curvature of spine, shortness of 
the extremities, and curvature of bones shown (Fussell, McCombs, deSchweinitz, and 
Pancoast). 



2l8 DISEASES OE CHILDREN FOR NURSES 

EPILEPSY 

The disease apparently depends upon the instabihty 
of the motor centers, so that from trivial exciting causes 
violent discharges occur from time to time. The disease 
is divided into grand mal and petit mat. 

S5miptoms. — Grand Mal. — A pecuhar sensation called 
an aura sweeps like a wave over the child. This is 
followed by unconsciousness and violent general con- 
vulsions, clonic in type. The child bites its tongue and 
froths at the mouth. The convulsion lasts for a few 
minutes and is followed by coma and later by automatism, 
in which the child performs certain automatic acts. 

Convulsions occur at varying intervals, showing a 
tendency to increase in number and severity. 

Petit mal is exhibited by momentary loss of conscious- 
ness with pallor, without convulsive movements. 

Treatment. — For the Attack. — This consists in measures 
to prevent the children from injuring themselves. Some- 
thing should be placed in the mouth to prevent biting of 
the tongue; further than this nothing can be done. If 
they should show any vicious traits after a convulsion, they 
should be carefully watched, as they are not responsible. 

Prophylaxis. — Nitrite of amyl inhalations will at times 
ward off an attack. 

HYSTERIA 

Hysteria is a functional disease of the nervous system 
associated with impaired will power and increased sensi- 
tiveness to impressions. Hysteric children are ill and 
should be treated accordingly. 

The disease is very rare in childhood before the seventh 
or eighth year, and most cases appear after the tenth year. 



NERVOUS DISEASES 219 

Etiology.— The children most affected are those who 
have inherited a nervous disposition, or in whose parents 
insanity, hysteria, or alcohoHsm have been present. 

The chief exciting causes are those which lead to a 
highly nervous condition in children whose general nutri- 
tion is faulty, such as anemia, chlorosis, or overpressure 
at school. It may follow the infectious diseases, or 
result from an injury, fright, or imitation. 

Symptoms. — These vary so that it is hard to classify 
them in any definite form. 

Psychic symptoms usually predominate. The children 
may have periods of mental depression, indifference to 
surroundings, a change in disposition, or periods of 
weeping and laughing without cause. Fits of temper, 
hallucinations, disturbances of sleep, and a development 
of a tendency to deception. Older children may actually 
simulate symptoms of various diseases, which they may 
have witnessed or about which they have read. 

Sensory Symptoms. — There may be areas of the body 
which become highly sensitive (hyperesthesia), so as to 
simulate inflammation of the various organs. More 
rarely areas develop of lost sensation (anesthesia). In 
addition, there may be headache with great tenderness 
of the scalp, neuralgias of different parts of the body, 
severe pains in the stomach, sometimes accompanied with 
vomiting, deafness, and blindness, usually of short dura- 
tion. 

Joint Symptoms. — All forms of organic disease of the 
joints may be simulated. The symptoms are most often 
referred to the spine and the large joints of the lower 
extremities. They may develop deformities. 

Motor Symptoms. — Many varieties of spasm are seen. 



220 DISEASES OF CHILDREN FOR NURSES 

These may affect the eyes, face, mouth, neck, or respira- 
tion. Hiccup and cough may be severe. 

General hysteric convulsions may be observed, 
though these are rare in childhood. In these convulsions 
consciousness is not fully lost and hallucinations are 
present. 

Hysteric paralysis is not common in children. 

Nursing. — The best results are obtained by placing the 
child in a quiet retreat in charge of an intelligent nurse. 

Every means should be taken to encourage muscular 
development, keeping the nervous system in the back- 
ground. They should lead an outdoor life, keep early 
hours, have regular exercise; their education should be 
mapped out so as to avoid overpressure. Theaters and 
exciting books should be avoided. 

The diet should be plain, and all stimulants, including 
tea and coffee, forbidden. 

The nurse should be firm and kind, but must avoid 
sympathy. Massage and hydrotherapy may be ordered 
by the physician. 

CHOREA (ST. VITUS^ DANCE) 

A nervous affection especially common in childhood, 
and characterized by irregular movements which increase 
under excitement and cease during sleep. 

The first manifestations are usually those of awkward- 
ness in movement, and restlessness. These grow worse 
until the disease is fully advanced, when there are peculiar 
jerking, disorderly movements of the various members of 
the body or involvement of the whole body. The move- 
ment may be so marked that the child cannot use its 
arms in eating, it stumbles when walking, and grotesque 



NERVOUS DISEASES 



221 



expressions are produced from the involvement of the 
face. Involvement of the larynx causes stammering, 
involvement of the muscles of. the pharynx causes choking 
fits and difficulty in swallowing, involvement of the tongue 
causes its withdrawal to be associated with an audible 
click. When the child's attention is called to the move- 
ments they invariably become worse. Frequently a 
heart murmur develops. The disease lasts from six to 
ten weeks. 

Prognosis is good. Occasionally there are deaths from 
exhaustion. 

TETANY 

A tonic spasm of the muscles of the extremities. It 




Fig. 62. — Persistent form of tetany in a girl a year and a half old. Tetanic con- 
tractures of the arms and legs; hands in the "obstetric" position; feet in plantar flexion 
(Hecker, Trumpp, and Abt). 

gives rise to a peculiar position of the hand called the 
obstetric hand, in which the fingers are slightly bent, the 
thumb held almost at a right angle across the palm, and 
the whole hand is sHghtly everted. 

This spasm lasts for a variable length of time and can 
be excited by making pressure upon the nerve trunks 
and blood-vessels of the extremities (Trousseau'' s sign). 
The disease is usually associated with laryngismus strid- 
ulus and recovery nearly always takes place. 



222 DISEASES OF CHILDREN FOR NURSES 

HABIT SPASM 

A peculiar form of spasm caused by habitual grimaces 
or movements of the head, finally becoming uncontrollable. 
This condition is also called tic, 

NYSTAGMUS 

A constant movement of the eyes. It may be lateral, 
horizontal, or rotary. 

NODDING SPASM OR SPASMUS GYRANS 

A peculiar form of movement seen in children charac- 
terized by a continuous nodding of the head. It is asso- 
ciated with nystagmus. Recovery usually takes place 
in a month or two. 

INJURIOUS HABITS 

Sucking, nail-biting, head-banging, masturbation, in- 
ordinate appetites for various substances, such as dirt, 
hair, and threads, are all practices which are injurious and 
should be controlled immediately. The longer the habit 
has lasted, the more difficult it is to break. 

TORTICOLLIS OR WRY-NECK 

This is a tonic spasm of the sternomastoid muscle. 
At times it is persistent. 

Treatment. — If due to rheumatism the neck should be 
ironed with a hot iron, over a piece of flannel first laid 
on the skin for protection. 

Disorders of Speech. — Stuttering or stammering and 
lisping are the most common. 



NERVOUS DISEASES 



223 



Disorders of sleep, such as night terrors^ are common. 
The children awake from sleep with a cry of terror; they 




Fig. 63. — Torticollis in a child two years of age (Friihwald and Westcott). 

fail to recognize those around them, and they exhibit 
symptoms of fright. 

Diseases of the Spinal Cord 

The junctions of the different columns of the spinal 
cord are: The anterior and lateral columns — motor; 
the posterior columns — sensory; the anterior horns of 
gray matter — trophic and motor. 

MYELITIS 

Myleitis is an inflammaton of a segmant of the cord 
involving the anterior, lateral, and posterior columns and 
the gray matter. 



224 DISEASES OF CHILDREN FOR NURSES 

S5rmptoms. — At first there is irritation, producing 
pain and fever. The pain is a pecuhar one called a 
girdle pain. The reflexes are increased; there are pares- 
thesias and convulsive movements. Later, when the 
inflammatory product becomes sufficient to produce 
pressure, there is a loss of sensation instead of pain and 
paresthesias. The reflexes are lost, there is paralysis 
instead of convulsions, and there is degeneration of the 
muscles and bed-sores. 

SCLEROSIS 

Sclerosis is an atrophy of the structure of the part 
affected with an overgrowth of connective tissue. Sclerosis 
in the spinal cord is an atrophy of the nerve elements 
and an overgrowth of the neurilemma (the connective 
tissue of the cord). 

Lateral sclerosis is the term appHed when this degen- 
eration attacks the lateral columns of the cord. This 
disease does not affect the sensory fibers; the main motor 
fibers which run through the anterior columns are intact 
and there are no trophic disturbances. 

Symptoms. — Exaggerated knee-jerks, ankle-clonus, and 
a spastic gait, sometimes spoken of as scissors gait. 

Acute Anterior Poliomyelitis or Infantile Paralysis. 
■ — This is an acute disease which occurs almost exclu- 
sively in young children, and is characterized by the 
destruction of nerve-cells in the brain and spinal cord, es- 
pecially in the anterior horns of gray matter. 

Since 1907 epidemics of infantile paralysis have been 
prevalent in Europe and the United States. Flexner and 
Lewis in their epoch-making studies having proved it to 
be an infectious and probably a contagious disease. The 



NERVOUS DISEASES 225 

virus of infection most probably gains access to the central 
nervous system through absorption from the mucous 
membrane of the nose and throat, from whence it is carried 
by the lymphatics through the cribriform plate of the 




Fig. 64 — Scissors gait in a girl two years old (Friihwald and Westcott). 

•ethmoid bone directly into the cranial cavity. The poison 
is likewise thrown off from the same mucous membrane 
by a reversed process of elimination. 

Symptoms. — The paralysis comes on very suddenly. 
The child goes to bed well and the following morning he 

IS 



226 DISEASES OF CHILDREN FOR NURSES 

cannot move his legs or, at times, his arms. Certain 
groups of muscles in the upper and lower extremities are 
involved, chiefly the latter. The paralysis at first is wide- 
spread, but tends to improve up to a certain point, where 
it remains stationary. The muscles affected atrophy, and 
the usefulness of the limb is obtained by an overdevelop- 
ment of other muscles which perform the function of the 
muscles which have been destroyed to a limited degree. 



Fig. 65. — Spinal infantile paralysis in the stage of fully developed palsy. Three-year- 
old girl (F. Lange). 

Treatment. — The nose and throat, being the principal 
points of infection, should be thoroughly douched with 
antiseptic solutions containing hydrogen peroxid and 
menthol. This not only applies to the children attacked, 
but to all children when the disease is epidemic. 

Flexner urges with emphasis that this should be 
thoroughly done. All nasal discharges should be dis- 
infected and destroyed. Adults in contact with the 
case should use the same precautions. It must also be 



NERVOUS DISEASES 22/ 

recognized that this infection may last for some time in 
the affected child, when he may act as a "carrier," so 
the antiseptic precautions should be continued over a 
period of several months. In epidemics of the disease it 
is well to quarantine the case for one month. 

The most important measure at the onset of the attack 
is to secure complete rest. Uro tropin, in rather large 
doses, is the drug usually given. The reason it is 
used is on account of the failure of animals to develop 
paralysis in many instances when the drug is given 
simultaneously with or shortly after the injection of 
the virus. 

After all acute symptoms have subsided, or at the end 
of two or three weeks, the nurse may be called upon to 
give electricity, friction rubs, massage, and manipula- 
tions to improve the circulation and nutrition of the 
limb, and they should be faithfully continued twice a 
day for a long period. 

The paralyzed children often have to undergo ortho- 
pedic operation upon tendons and joints, and they fre- 
quently have to wear braces. 

Syringomyelia is a disease of the spinal cord in which 
there is a cavity in the cord. 

Landry's paralysis is an ascending form of paralysis 
beginning in the legs and rapidly involving the entire 
body. 

Friedreich's ataxia is a form of sclerosis of the spinal 
cord which develops in childhood and lasts from twenty 
to thirty years. 

Atrophies of the muscles of different parts of the body 
are seen, due to disease of the spinal cord. 

Pseudohypertrophy of the muscles is a condition in 



228 DISEASES OF CHILDREN FOR NURSES 

which the muscles are apparently enlarged, but actually 
are degenerating. 

Diseases of the Nerves 
NEURITIS 

Neuritis is an inflammation of a nerve, and is character- 
ized by pain and tenderness along the course of the nerve. 
It is associated with various forms of paresthesias. The 
part suppHed by the nerve is at first hyperesthetic, later 




Fig. 66. — Bell's palsy. The child is crying, only one side of the face shows the 
emotion, due to paralysis of the muscles of expression on the other. 



anesthetic. In severe inflammations paralysis of the 
part supplied by the nerve develops. 

Sciatica is inflammation of the sciatic nerve character- 
ized by the above symptoms along its course in the pos- 
terior part of the thigh. It is worse at night and at the 
approach of stormy weather. 

Multiple neuritis is an inflammation of a number of 



NERVOUS DISEASES 22g 

nerves. The most common cause in childhood is diph- 
theria. 

Symptoms. — There is pain over the deep nerve-trunks, 
paralysis, and wrist-drop and foot-drop due to paralysis of 
the extensor muscles. 

Postdiphtheritic paralysis is a form of multiple 
neuritis occurring after diphtheria in which the muscles of 
swallowing are at first attacked, the other muscles of the 
throat and body being successively involved. Recovery 
usually follows. If the children die the cause of death is 
heart failure due to paralysis of the pneumogastric nerve 
(see page 326). 

Bell's Palsy. — A paralysis of the muscles of expression 
(Fig. 66) affecting one side of the face and due to in- 
jury or disease of the seventh cranial nerve. 

NURSING IN NERVOUS DISEASES 

When symptoms of irritation of the central nervous 
system exist the child should be placed in a dark room, 
kept as quiet as possible, and the covers should be sup- 
ported by a frame to prevent the discomfort of their 
weight. 

Scrupulous cleanliness must be employed to prevent 
bed-sores. The position of the child must be frequently 
changed, parts resting upon the bed must be protected, 
using air-cushions and water-beds for this purpose. 

The symptoms developing in the course of nervous 
diseases must be accurately recorded, convulsions must 
be observed, and their starting-point, character, extent, 
and duration reported. 

In lumbar puncture the fluid is collected in a sterile 
test-tube with an aseptic cotton stopper. 



230 DISEASES OF CHILDREN FOR NURSES 

At times feeding must be administered by the medicine, 
dropper, gavage, or enema. 

In chorea the extremities should be bandaged to protect 
them from chafing. Pull all sheets very tight and dispense 
with the "draw sheet." Remove all crumbs immediately 
and apply powder to bed frequently. 

The temperature, pulse, and respirations should be 
taken three times a day. 



CHAPTER X 

DISEASES OF THE URINARY TRACT 

The urinary tract consists of the kidneys, two in number, 
situated on the right and left side of the body beneath the 
edge of the ribs, posteriorly; the ureters, which run from 
the pelvis of the kidneys; the bladder; and the urethra. 

THE KIDNEYS 

Anatomy. — The kidney is divided into the cortical area, 
the medulla or pyramidal, and the pelvis. 

The urinijerous tubules start in the glomeruli which 
are situated in the cortical area of the kidney. 

The glomeruli are tufts of capillaries surrounded by a 
capsule. The epithelial cells lining the capsule and tubes 
abstract from the blood current the products which 
form the urine. The tubes run from the capsules and 
after pursuing a very tortuous course they empty at the 
apex of one of the Malpighian pyramids. It is in these 
tubules that the urinary products are formed. They are 
emptied from the mouths of the uriniferous tubules, at the 
apices of these pyramids, into the pelvis of the kidneys, 
and from here the urine passes through the ureters into 
the bladder and is voided through the urethra. 

From these tortuous uriniferous tubules the tube-casts 
are formed. They are cylindric in shape and usually 
composed of the Hning epithelium in various stages of 

231 



232 



DISEASES OF CHILDREN FOR NURSES 



degeneration. Their formation is something on this 
order: The lining epithehum of these tubes is the fikei 
which extracts the uriniferous products from the blood. 
As long as this epithelial lining is intact the urine is 
normal; when there is congestion or inflammation of the 
kidneys the tubules shed this lining membrane. This 
appears in the urine as casts, and as the wall between the 




Fig. 67.— a longitudinal section of the kidney, a, Renal artery; c, cortex; m, medulla; 

M, ureter (Leroy). 

blood current and the tubules is destroyed there is an 
outflow of red blood-corpuscles and albumin. This 
is the condition seen in acute congestion, or acute nephritis, 
the name for inflammation of the kidneys. In chronic 
nephritis fatty casts are found. 

Malformations of the kidneys are not common. 
Those seen occasionally are horseshoe kidney^ where 



DISEASES OF THE URINARY TRACT 233 

the two are fused, forming one large crescentic kidney; 
supernumerary ureters; -floating kidney; and single kidney. 

THE URINE 

Normal urine is pale, amber colored, of acid reaction, 
and has a specific gravity of T015 to 1025. 

Polyuria is the term appHed to an increase in the quan- 
tity of the urine, and may be a temporary polyuria, such 
as is seen in excessive ingestion of fluids, the suppresison 
of perspiration, etc. 

Permanent polyuria may result from such conditions as 
diabetes melHtus, diabetes insipidus, chronic interstitial 
nephritis, and amyloid kidney. 

Anuria is the term appHed to a diminution in the flow 
of urine. It is seen in the following conditions : Excessive 
secretion through other channels, such as profuse perspira- 
tion and diarrhea; in fever; passive renal congestion from 
obstructive disease of the heart, lung, or liver; organic 
obstruction in the urinary passages; in acute or chronic 
parenchymatous nephritis; from nervous causes such as 
hysteria; and in the reflex inhibition after abdominal 
injuries or operations. 

Urea results from the perfect decomposition of the 
nitrogenous elements of food and tissue. It is, therefore, 
a normal constituent of the urine. In health the amount 
excreted varies greatly. Normal urine contains about 
2 to 2\ per cent, of urea. When there is imperfect meta- 
morphosis of tissues and nitrogeous food there is the 
formation of uric-acid crystals in the urine. When they 
are in excess the urine is heavy, dark in color, and on 
cooling throws down a brick-red deposit. When uric 
acid or urates are found in the urine it is termed lithuria. 



234 DISEASES OF CHILDREN FOR NURSES 

Glycosuria is the name applied to urine containing 
sugar. It is caused by diabetes mellitus and at times by 
chorea, tetanus, and functional nervous affections; in- 
digestion of a large amount of saccharine material, lesions 
of the pancreas, Hver, and base of the brain. 

Albuminuria is the name appKed to the presence of 
albumin in the urine. It is found in all forms of nephritis 
and in congestion of the kidneys, resulting from chronic 
disease of the heart, lung, or liver. 

Cyclic Albuminuria. — The urine may be albuminous at 
certain times, as after meals, bathing, or rising in the 
morning. 

Accidental albuminuria results from the admixture of 
albuminous substances v^ith the urine, as pus and blood. 
It is found in certain nervous diseases, as epilepsy, tetanus, 
and injuries to the brain, extreme anemia, and the ingestion 
of large amounts of albuminous foods. 

Hematuria. — Blood in the urine. 

Hemoglobinuria. — Blood-pigment in the urine. 

Choluria. — Bile in the urine. 

Chyluria. — Chyle in the urine. 

Pyuria. — Pus in the urine. 

Indicanuria. — Indican in the urine. It is a symptom 
of chronic indigestion. 

Method of Collecting Urine. — In males the penis can 
be placed in the neck of a bottle which lies between the 
thighs, and is held in position by a square of adhesive 
plaster, the center of which is pierced, making a hole large 
enough to grip the neck of the bottle. 

In females a small pan placed under the buttocks will 
answer, or a bottle may be arranged as described above. 
If these methods fail, cathetexize (see page 471). 



DISEASES OF THE URINARY TRACT 235 

Average Daily Quantity of Urine in Health 

Age Ounces 

First twenty-four hours o to 2 

Second twenty-four hours J to 3 

Three to six days 3 to 8 

Seven days to two months 5 to 13 

Two to six months 7 to 16 

Six months to two years 8 to 20 

Two to five years 16 to 26 

Five to eight years 20 to 40 

Eight to fourteen years 32 to 48 

(Holt). 

Examination of Urine. — The color is noted and any 
sediment is recorded. The acidity or alkalinity is deter- 
mined. 

The speci-fic gravity is found by means of a urinometer. 
This is an instrument weighted with mercury and having 
a scale on the stem graduated from 1000 up. By floating 
this instrument in a quantity of urine the specific gravity 
of the specimen can be read off. The point at which 
the top of the hquid is indicated on the scale is the proper 
specific gravity. 

Albumin is tested for by boiling a small quantity of 
urine in a test tube. It should be clear urine, filtered 
if necessary. If albumin is present the urine will cloud 
when boiled, and if upon the addition of a few drops of 
acetic acid it does not clear, albumin is present. If it 
does clear the precipitate is composed of phosphates. 

Heller^s Test. — -Another test used consists in placing a 
small amount of nitric acid in a test-tube and allowing the 
urine to run slowly down the sides of tube in such a 
manner that it will float on the surface of the nitric acid. 
If albumin is present there will be a white line at the point 
of contact of the two Hquids. A brown Hne denotes 
uric acid. 



236 DISEASES OF CHILDREN FOR NURSES 

Sugar is tested for by Fehling's solution. This consists 
of two parts: One is bluish-green (composed of copper 
sulphate) and the other is white (composed of rochelle 
salts and caustic potash). Equal parts of each are added 
to four times their volume of water and the mixture 
boiled. If it retains its bluish color it is suitable for a test. 
A few drops of urine are added to the solution and boiled, 
and if sugar is present, a reddish-yellow precipitate is 
thrown down. The test is very accurate. 

Microscopic examination is necessary to determine the 
presence or absence of casts, red blood-cells, white blood- 
cells, and epithelium. 

Such substances as bile in the urine have special tests. 

DIABETES INSIPIDUS 

Diabetes insipidus is a chronic condition characterized 
by the excretion of large quantities of pale, limpid urine 
of low specific gravity and free from albumin and sugar. 

In addition to the urinary symptoms there is an insati- 
able thirst, good appetite, a harsh, dry skin, a dry tongue, 
constipation, mental apathy, and emaciation. 

RENAL HYPEREMIA 

Active hyperemia is caused by arterial blood and is 
found in all acute congestions. It is due to exposure 
when the body is overheated. The same cause, aggra- 
vated, would cause acute nephritis. 

Passive hyperemia is due to venous stasis and is 
found in all chronic congestions. 

Acute Congestion. — Symptoms of acute congestion 
are pain over the loins; dark and scanty urine of high 
specific gravity, and perhaps containing a trace of albumin, 
a few hyaline casts, and some free blood. 



DISEASES OF THE URINARY TRACT 23/ 

Passive congestion of the kidneys is caused by condi- 
tions which obstruct the general circulation, such as 
chronic disease of the heart, Hver, and lung; pressure of 
tumors upon the renal veins, and, rarely, thrombosis of 
the renal veins. The kidney is swollen, and in protracted 
cases becomes hard from an overgrowth of connective 
tissue. 

Symptoms. — There is a sensation of weight over the 
loins; the urine is usually diminished in quantity; rarely 
increased. Free blood, a trace of albumin, and occa- 
sionally a few hyaline casts are found. 

UREMIA 

Uremia is the name applied to a group of symptoms 
which result from the retention of toxic materials in the 
blood which should have been ehminated by the kidneys. 

Symptoms. — The disease may develop slowly or abruptly 
and may manifest any of the following phenomicna : head- 
ache, vertigo, dehrium, epileptiform convulsions, coma, 
sudden bhndness (unassociated with any retinal change), 
and transient paralysis from congestion of the brain or 
cord. 

Pulmonary symptoms are dyspnea (uremic asthma), and 
Cheyne-Stokes respiration. 

Abdominal symptoms are hiccough, obstinate vomiting, 
and purging. 

General Symptoms. — The skin is dry, the breath has a 
urinous odor, the urine is scanty and deficient in urea. 
The pulse is slow and full, the temperature is subnormal, 
but during a convulsion the temperature may rise and the 
pulse become rapid and feeble. 

Prognosis. — Grave, but always guarded, for recovery 



238 DISEASES OF CHILDREN FOR NURSES 

is possible after the most serious complications and 
manifestations. 

Treatment. — The object of the treatment is to eliminate 
the poison as rapidly as possible. To accomplish this 
the physician takes advantage of every possible excretory 
function. He promotes catharsis (purging) and free 
diaphoresis (sweating). In some cases bleeding and 
the intravenous injection of normal salt solution is prac- 
tised. Convulsions may be controlled by inhalations of 
chloroform. Morphin should be used with great care, 
as it frequently aggravates the case. 

NEPHRITIS 

Acute nephritis is an acute inflammatory disease 
involving more or less of the whole kidney, but it especially 
affects the epithelium of the tubes and glomeruli. 

Other names given to this condition are acute Bright's 
disease and acute parenchymatous nephritis. 

Etiology. — Exposure to cold and wet, the specific fevers, 
especially scarlet fever, and certain poisons. 

Pathology. — The kidney is swollen, the capsule is 
nonadherent. At first the organ is bright red in color, 
but it soon becomes pale and mottled in appearance. 

Histology. — The epithelium of the tubes and of the 
glomeruli is the seat of the cloudy swelHng and, later, of 
fatty degeneration. Desquamated epithehum, blood cor- 
puscles, and an albuminous exudate block up the tubules. 

Symptoms. — In some cases moderate fever 'with its 
associated phenomena, dull lumbar pains, nausea and 
vomiting, dropsy, beginning in the face and becoming 
general, and rapid anemia. Uremic symptoms may 
develop at any time. The urine is scanty and at times 



DISEASES OF THE URINARY TRACT 239 

suppressed. It is smoky in appearance, of high specific 
gravity, rich in albumin, and throws down a heavy sedi- 
ment which contains hyahne, blood, and epithehal casts 
and free blood and epithelial cells. As the general symp- 
toms are often sHght, the diagnosis of the condition must 
rest upon the urinary analysis. 

Prognosis. — Guardedly favorable. It may kill by ex- 
haustion, uremia, or dropsy, and it may become chronic. 

Treatment. — The disease demands absolute rest in bed 
until the albumin has entirely disappeared from the urine. 
Milk is the best food, although butter-milk, gruels, and 
light broths are admissible. The free use of water should 
be encouraged. Free action of the skin is secured by 
means of vapor baths and the bowels are kept loose by 
concentrated saline draughts, as Rochelle and Epsom 
salts. Uremia will call for its appropriate treatment. 
Marked effusions in the serous cavities will sometimes 
demand aspiration. Convalescence should be protracted. 

Chronic parenchymatous nephritis may result from 
acute nephritis or it may be chronic from the beginning. 
Congestion from heart disease is the usual cause. 

Pathology. — In the first stage the kidney is large and 
pale yellow in color, the pallor depending upon the anemia 
and the fatty degeneration. The tubes are filled with 
fatty epithelium and casts, and there is always some over- 
growth of the interstitial connective tissue. 

In the second stage the organ is small, pale in color, 
its surface rough, and its capsule somewhat adherent. 
The reduced size depends upon the destruction of the 
renal epithelium and the contraction of the overgrown 
connective tissue. 

Symptoms. — As the disease usually begins as a chronic 



240 DISEASES OF CHILDREN FOR NURSES 

affection the following symptoms slowly make themselves 
manifest: progressive loss of flesh and strength, marked 
anemia, gastro-intestinal disturbances, dropsy, often first 
noted in the face on arising in the morning; increased 
arterial tension, some hypertrophy of the left ventricle of 
the heart so that the second sound at the aortic cartilage 
is accentuated. Uremic symptoms may develop at any 
time. 

The urine is usually diminished although it is often 
normal in color and appearance. It is highly albuminous 
and throws down an abundant sediment which contains 
hyahne, fatty, and granular casts, and fatty epithelium. 
The process is a chronic one and the epitheUum and the 
casts have undergone fatty degeneration. 

Complications. — These are numerous and often suggest 
the diagnosis. The most common are uremia, extensive 
dropsy into the tissues or serous cavities, valvular heart 
disease, albuminuric retinitis (an eye condition interfering 
with vision), and acute exacerbations (an acute paren- 
chymatous nephritis occurring during the course of the 
chronic attack). 

Treatment. — The treatment is largely hygienic and 
dietetic. Residence in a dry, warm, and equable climate 
may prolong life or affect a cure. Rest is an essential 
element in the treatment. The underclothing should be 
woolen or silk in order to keep the skin constantly active. 
The diet should be non-nitrogenous and in severe cases 
an absolute milk diet may be of extreme value. The 
bowels should be kept active by mineral waters. 

Chronic Interstitial Nephritis. — This disease, rare in 
childhood, is a chronic inflammatory condition of the 
kidney characterized by a reduction in its size due to an 



DISEASES OF THE URINARY TRACT 24 1 

overgrowth and a subsequent contraction of its connective- 
tissue elements. It may be associated with general arterio- 
sclerosis and cardiac hypertrophy. 

Etiology. — The disease may be secondary to paren- 
chymatous nephritis or it may result from the chronic 
congestion of chronic heart disease; but it generally arises 
as a primary condition and results from the causes which 
predispose to sclerosis in other organs. 

Pathology. — The kidneys are small and red in color. 
The surface is granular and the capsules adherent. Small 
cysts are often present. The microscope shows a great 
overgrowth of connective tissue which has contracted, 
narrowing the lumen of the tubules and interfering with 
the nutrition of the epithelium, and as a result the epithe- 
lium may show fatty degeneration with desquamation. 
The arteries throughout the body may show sclerosis, and 
from the resistance thus offered hypertrophy of the heart 
results. 

Symptoms. — A slow loss of flesh and strength with pro- 
gressive anemia. Gastric disturbances are very common. 
The arteries may be rigid and the pulse is of high tension, 
so that the second sound of the heart is accentuated at the 
aortic cartilage. Palpitation of the heart is often noted. 
Dyspnea is a prominent symptom and may result from 
heart weakness, uremia, or edema of the lungs. Head- 
ache, vertigo, and insomnia often result from disturbed cir- 
culation and dimness of vision from albuminuric retinitis. 
Dropsy is often absent or is sHght and appears late in the 
disease. 

The urine is increased in quantity, pale in color, and of 
low specific gravity, 1005 to loio; it contains but a trace 
of albumin and a few narrow hyaline casts. 

i6 



242 DISEASES OF CHILDREN FOR NURSES 

Diagnosis. — The difference between chronic interstitial 
nephritis and chronic parenchymatous nephritis is that 
in the latter the urine is rich in albumin and tube-casts 
and the disease is seen in earlier life; it lacks much arterial 
change and produces considerable dropsy. 

Chronic interstitial nephritis is so insidious that it is 
scarcely ever discovered except by accident. Either it is 
discovered in the routine examination or, as frequently 
happens, not until uremia develops, when often it is too 
late to do anything. 

The treatment is practically the same as in chronic 
parenchymatous nephritis. 

AMYLOID KIDNEY 

Amyloid kidney is a name given to the large white 
kidney found after prolonged suppuration, particularly 
bone disease; in tuberculosis, syphilis, and malarial 
cachexia. 

The urine is increased, there is considerable albumin, 
and wide hyaline and granular casts. 

RENAL CALCULUS 

Renal calculus is a precipitated urinary concretion 
found in the kidneys. The stone may he latent indefi- 
nitely or it may pass out with or without symptoms of 
cohc. It may obstruct the ureter or excite inflammation 
of the kidney or even abscess. 

Symptoms of Renal Colic. — Sudden onset with sharp 
pain, starting in the back and radiating down the ureter 
into the penis, testicle, or thigh. The symptoms of intense 
pain are present: pallor, cold sweats, weak pulse, and 



DISEASES OF THE URINARY TRACT 243 

reflex vomiting. The urine subsequently passed may 
contain the stone, or, as a result of irritation, pus, blood, 
and desquamated epithehum. An attack may last from 
a few moments to several hours. 

Treatment. — The physician will probably use hypo- 
dermics of morphin and atropin, and inhalations of 
chloroform if necessary. The free use of water should 
be encouraged, and hot applications placed over the loins. 

PYELITIS 

Pyelitis is the name given to an inflammation of the 
pelvis of the kidney. 

HYDRONEPHROSIS 

This is a dilatation of the pelvis of the kidney with an 
accumulation of watery fluid resulting from obstruction. 
It is caused by strictures, tumors, and impacted stones. 

FLOATING KIDNEY 

This condition is rare in childhood. The kidney is 
distinctly mobile, due to a relaxation of the tissues which 
surround it. The right kidney is the one usually affected 
and may be found in any part of the abdomen. 

TUBERCULOSIS OF THE KIDNEY 

This condition is usually secondary to tuberculosis 
elsewhere, although it may be primary. It is always 
grave; the patients may hve from a few months to three 
years. 



244 



DISEASES OF CHILDREN FOR NURSES 



SARCOMA OF THE KIDNEY ' 

Sarcoma of the kidney is a malignant tumor of the kidney 
which is sometimes seen in children. The organ affected is 
removed at times by surgical means. It is ultimately fatal. 




Fig. 68. — Sarcoma of both kidneys in a male child two years of age. The tumors are 
here outlined to show their extent (Napier). 

NURSING IN KIDNEY DISEASES 

In nephritis the room should be warm to facilitate the 
action of the skin. 
Vapor baths are necessary at times (see page 436). 



DISEASES OE THE URINARY TRACT 245 

Woolen underwear should be worn to stimulate per- 
spiration. 

The child should lie between blankets while in bed. 

A specimen of the urine should be saved daily, unless 
otherwise ordered. The total quantity of urine passed 
in twenty-four hours should be measured. 

The feeding should be carried out strictly in accordance 
with instructions. 

Any symptoms of uremia, such as convulsive move- 
ments, intense headache, or stupor should be immediately 
reported. 

The temperature, pulse, and respirations should be 
taken at least three times a day. 

THE BLADDER 

Enuresis is the inabihty of a child to hold its urine. 
In infancy urination is a reflex act beyond the control 
of the will. After the second year, and often before this 
age, a child should be able to retain the urine until a 
suitable time and place for voiding is reached. After two 
years involuntary urination is spoken of as enuresis. If 
it occurs at night it is called nocturnal, and if in the day- 
time, diurnal. In some cases it occurs both during the 
day and at night. 

The children suffering from enuresis are usually anemic, 
underdeveloped, and of a very nervous disposition. 

Treatment. — Plenty of sleep and a diet of milk, vege- 
tables, fruits, meats, and cereals should be adhered to. 
Often a case of nocturnal enuresis can be controlled by 
awakening a child at eleven or twelve o'clock at night 
and making him void urine. Another way is to get the 
child to hold urine as long as possible in the day-time. 
This accustoms the sphincter to retain the urine. Medical 



246 DISEASES OF CHILDREN FOR NURSES 

treatment is usually necessary. Circumcision at times 
relieves, if there is a long foreskin. 

Vesical spasm is a frequent and painful micturition 
usually due to highly acid urine. 

Vesical calculus is a stone in the bladder. This gives 
rise to painful micturition and straining, which at times 
causes prolapse of the rectum. Occasionally there is sud- 
den stoppage of the flow and pain ia the end of the penis. 

MALFORMATIONS OF THE GENITAL TRACT 

Phimosis is a narrowing of the prepuce or foreskin so 
that it cannot be retracted. This condition gives rise to 
irritation from accumulation of smegma beneath the skin, 
obstruction to the flow of urine, enuresis, and masturbation. 

Treatment. — Circumcision should be done in all cases 
of phimosis. If the child is vigorous, two years of age is 
the best time for an operation. 

Hypospadias. — A malformation of the penis in which 
the urethra is not continued to the end of the glans, the 
orifice being on the under surface of the penis. 

Epispadias. — The opposite of hypospadias, the orifice 
being on the upper surface of the penis. 

Exstrophy of the Bladder. — A failure on the part of 
nature to complete the abdominal wall over the bladder. 
The bladder is in sight and often fissured so that the 
urine discharges from it. 

Undescended Testicle. — Before birth the testicles lie 
beneath the kidneys. They descend into the scrotum 
during the ninth month of pregnancy. At times they 
fail to descend. An undescended testicle usually hes in 
the inguinal canal. Serious symptoms rarely attend this 
deformity. 



DISEASES OF THE URINARY TRACT 247 

DISEASES OF THE MALE GENITALS 

Balanitis. — Inflammation of the prepuce or foreskin. 

Treatment. — ^Wash with i to 5000 solution of bichlorid 
of mercury, syringing beneath the foreskin. 

Urethritis. — Inflammation of the urethra. The chief 
symptoms are painful urination and a discharge. This 
discharge may be a simple catarrhal discharge or it may 
be gonorrheal. If the latter, gonorrheal infection of the 
eyes {gonorrheal conjunctivitis) must be very carefully 
guarded against. The parts should be covered and 
kept clean. 

Hydrocele. — This is a collection of serous fluid in the 
testicle or along the inguinal canal. 

DISEASES OF THE FEMALE GENITAL TRACT 

Vaginitis. — An inflammation of the vagina. The chief 
symptom is a yellowish discharge from the vagina. It 
may be catarrhal or gonorrheal. The gonorrheal form 
is highly contagious and very obstinate. It may cause 
gonorrheal conjunctivitis (inflammation of eye) with a 
loss of sight. 

Girls suffering from vaginitis should not be allowed to 
associate with other children and their towels and diapers 
should be steriHzed. The parts should be kept scrupu- 
lously clean and well protected, and frequent douches of a 
solution of bichlorid of mercury, i to 10,000; potassium 
permanganate, i to 10,000; saturated solution of boric 
acid, or normal salt solution administered (see page 453). 

NURSING IN DISEASES OF THE GENITAL TRACT 

Whenever a discharge exists from the male or female 
generative organs the nurse should thoroughly sterilize 



248 DISEASES OF CHILDREN FOR NURSES 

her hands after cleansing ihe parts so as to prevent any 
infection of her eyes. If possible, rubber gloves should be 
worn. 

To prevent the spread of vaginitis either in a hospital 
or in a private family the greatest precautions must be 
taken. A child affected should have a separate bed-pan, 
douche-bag, thermometer, eating utensils, playthings, etc. 
If possible, all articles which come in contact with the dis- 
charge should be sterilized after using. All linen should 
be boiled, and all soiled articles, such as cotton, etc., 
should be soaked in carbohc acid, i to 20, before disposal. 

A pad should be woi*n, which should be immediately 
burnt when discarded. 

Vaginal suppositories are used in treating this disease 
by many physicians. They must be carefully inserted. 



CHAPTER XI 

DISEASES OF THE EYE, EAR, SKIN, AND 
GLANDULAR SYSTEM 



THE EYE 

Anatomy. — The eye is a globe composed of three 
coats: the sclerotic, the choroid, and the retina. The 
retina is the sensitive coat; it receives the impressions of 
the objects seen and transfers them through the optic 
nerve to the brain. 

The anterior portioa of the eyeball is composed of the 
cornea, a transparent membrane. 

Ocular muscle 



Sclera 
Choroid 



Ciliary muscl 

Iris. 

Conjunct, cul-de-sac 

Anterior chamber and 

aqueous humor 

Crystalline lens 

Posterior chamber 

Angle of antechamber 

Suspensory ligament 

of the lens 




Retina 



Optic nerve 
with central 
retinalartery 

Ocular 
muscle 



Cornea Vitreous chamber 

Fig. 69. — Vertical section through the eyeball and eyelids (Pyle). 

The iris is the curtain behind the cornea which shuts 
out the unnecessary rays of light. It has an opening in 
its center called the pupil. 

The eyeball is moved horizontally and vertically by the 

249 



250 DISEASES OF CHILDREN FOR NURSES 

superior, inferior, internal, and external recti muscles; in 
the oblique directions by the superior and inferior oblique 
muscles. 

The conjunctiva covers the eyeball and lines the lid; 
it is a mucous membrane. 

The lacrimal apparatus consists of the lacrimal gland 
which secretes the tears. The tears are poured over 
the eyeball from a duct at the inner canthus, and drain 
through a duct leading into the nose. 

The Meibomian glands are small glands in the upper 
lids which secrete a lubricating fluid. 

Definitions. — Photophobia. — Intolerance to light. 

Lacrimation. — Watering of the eye. 

Conjunctivitis. — An inflammation of the lining mem- 
brane of the lids and the covering of the eyeball. 

Keratitis. — An inflammation of the cornea. 

Ophthalmia. — An inflammation of the eye. 

Iritis. — An inflammation of the iris. 

Strabismus (Cross-eyes). — A paralysis of one of the 
rectus muscles. 

Synechia. — Adhesion of the iris to the cornea. 

Hordeolum. — A stye; a cyst of a Meibomian gland. 

Accommodation. — The power of the lens to change its 
form and shape so that objects nearby may be seen as 
readily and distinctly as those at a distance. 

Hypermetropia. — Far-sightedness, as the eyeball is too 
short. 

Myopia. — Near-sightedness. The eyeball is too long. 

Astigmatism. — A flattening of the convexity of a portion 
of the cornea or lens which blurs the vision. 

Stenosis oj the Lacrimal Duct. — A blocking up of the 
passage leading from the eye to the nose. 



DISEASES OF EYE, EAR, SKIN, AND GIANDS 25 1 

Malformations. — Anomalies of the eyes consist of 
flecks upon the iris, cross-eyes, congenital cataract, and 
albinism. 

Care of the Eyes. — Immediately after birth the eyes 
should be washed with a saturated solution of boric acid. 
This should be continued during the first week as a part 
of the daily bath. If the mother has had any vaginal 
discharge previous to the birth of the child, a drop of a 




Fig. 70. — Examination of the eye. If the patient be a rebellious infant, perfect 
control may be secured if he is held firmly upon the nurse's lap, the child's head being 
steadied between the knees of the examiner while the examination is made (Kerr). 

2 per cent, solution of nitrate of silver should be placed 
in each eye immediately after birth (Crede's method). 
This prevents ophthalmia neonatorum. For the method 
of syringing the eyes, see page 442. 

The newborn should be protected from too strong a 
light as it injures the sight; a dark room is the best. 

Objects are recognized by the infant when about five 
months of age. 

Ophthalmia neonatorum is an inflammation of the 



252 DISEASES OF CHILDREN FOR NURSES 

conjunctiva seen in the newborn. It is due to gonorrhea 
and is characterized by a purulent discharge from the eye. 
It very often causes bHndness. 

Conjunctivitis or Pink-eye. — An inflammation of the 
lining membrane of the eyehds and covering of the eyeball. 

Symptoms. — Pain in the eye, lacrimation, photophobia, 
and a discharge which may be catarrhal or purulent. 
The disease may be acute or chronic. 

Foreign bodies in the eye can be removed by turning 
the upper hd, if they are not visible. The lid can be 
turned by placing a card or match-stick at the center of 
the upper lid and pulHng the anterior portion upward 




Fig. 71 — Method of everting the upper eyelid (J. P. C. Griffith). 

by means of the eyelashes (see Fig. 71). A pledget 
of cotton will remove the speck. 

Keratitis. — An inflammation of the cornea. It is 
divided into phlyctenular, ulcerative, and interstitial 
keratitis. 

Symptoms. — Pain, lacrimation, and photophobia. In 
the phlyctenular variety small vesicles appear upon the 
cornea which may rupture and form shallow ulcers. 
Scars result from healed ulcers. In the interstitial form 
the inflammation is not upon the surface, but within the 
structure of the cornea. This form of the disease is due 
to hereditary syphilis. 



DISEASES OF EYE, EAR, SKIN, AND GIANDS 253 

Nystagmus consists of vibratory movements of the eyes, 
horizontally, vertically, or rotary. 

Nursing of Diseases of the Eye. — When a discharge 
from the eye exists the Hds should be held open and the 
conjunctiva syringed (see page 442) with a saturated 
solution of boric acid, repeated often enough to prevent 
any of the purulent matter from remaining in apposition 
to the inflamed surfaces for any length of time. The 
applications used are dropped in the eyes from a medicine- 
dropper. Cold and hot compresses are employed to 
combat inflammation and the discharge. 

Cold compresses are prepared by cutting small disks 
out of muslin, Hnt, or gauze and allowing them to lie on 
a piece of ice until cold. They are then laid over the 
eyelids. The compress must be changed every two min- 
utes because it will not remain cold for a longer period. 

Hot compresses are prepared in the same way, hot water 
being used instead of ice. 

Children suffering from inflammation of the eyes should 
be kept in a dark room. 

The nurse should always wash her hands in an anti- 
septic solution after treating ophthalmia, else she may 

infect her own eyes. 

THE EAR 

Anatomy. — The ear is divided into three divisions: the 
external or pinna, the middle ear, and the internal ear. 

The external ear or pinna is composed of cartilage, 
which is so arranged that it collects the air waves, and the 
auditory canal, which is about one inch long. 

At the internal end of the external auditory canal is the 
drum, or tympanic membrane, a small membrane about 
a half inch in diameter. 



254 



DISEASES OF CHILDREN FOR NURSES 



The middle ear contains three bones : the malleolus^ the 
incus^ and the stapes. The malleolus is attached to the 
drum and articulates with the incus, which in turn articu- 
lates with the stapes. They are so arranged as to form a 
system of communication between the drum and the 
inner ear, by means of which the vibrations of the drum 
are transmitted to the inner ear. 



Roo/yBoni/ ffead ^Afcdkus 



ScnUcircular Cetnals 




Facial T^irtK 



EustachUlan. Tuds 
laid open 



Fig. 72. — Frontal section of the organ of hearing (modified from Politzer). 



The Eustachian tube connects the middle ear with the 
pharynx. It is through this duct that inflammation 
extends from the pharynx and causes middle-ear disease 
{otitis media). 

The internal ear contains the organ of hearing called 
the cochlea. It is so arranged that the vibrations of the 
drum are transmitted to the terminal filaments of the 
auditory nerve. 

The semicircular canals maintain the equilibrium of the 



DISEASES OF EYE, EAR, SKIN, AND GLANDS 255 

body. Any disease or injury to them causes intense 
dizziness. 

The mastoid cells are in the mastoid process of the 
temporal bone. They connect with the middle ear. 

Definitions. — Impacted Cerumen. — The term given to 
large quantities of wax in the external auditory canal. 

F ur uncle oj Canal. — A small abscess of the auditory canal. 

Puncture oj Drum. — A rupture of the drum or tympanic 
membrane. 

Otitis Media. — -Inflammation of the middle ear. It 
may be catarrhal or purulent. Acute and chronic varieties 
are seen. 

Acute Otitis Media (Earache). — This is usually 
caused by an extension of inflammation from the pharynx 
along the Eustachian tube. It follows catarrh of the 
nose and throat, measles, scarlet fever, whooping-cough, 
and dentition. 

Symptoms. — There is pain in the ear with congestion of 
the drum and fever, from 99° F. to 102° F. The child 
seems ill without any definite signs of the seat of the lesion. 
In a great number of cases at the end of twenty-four or 
forty-eight hours there will be a discharge from the ear. 
It may be catarrhal or purulent in character. The intense 
pain improves after the appearance of the discharge, and 
the condition gradually improves. The discharge is not 
present without a rupture of the drum. Rupture of the 
drum does not interfere with hearing. 

In chronic otitis media the discharge is the character- 
istic symptom. It may persist for years. The purulent 
form has a disagreeable odor. 

Mastoiditis is an inflammation of the mastoid cells. 
It is caused by an extension of the inflammation from the 
middle ear. - - 



256 DISEASES OF CHILD J^ EN FOR NURSES 

Symptoms. — The characteristic symptoms are fever, 
103° F. to 104° F., with swelling and tenderness behind 
the ear. An operation is demanded in the case of mastoid 
abscesses. 

The dangers of mastoiditis are an abscess of the brain 
and septic thrombosis of the sinus of the brain and jugular 




Fig. 73- — Mastoid abscess. The characteristic manner in which the external ear is 
pushed forward by the abscess is here well shown (Kerr). 

veins. At times during the operation the facial nerve is 
injured, giving rise to Bell's palsy. 

Nursing and Treatment of Ear Diseases. — The 
methods employed are used to keep the ear clean, dry up 
the discharge, and treat the inflammation. Hot water, 
1 1 50 F., is the best agent to use in syringing the ear 
(for method, see page 443). It not only thoroughly 
cleanses but it reduces congestion. Nothing else should 
be used to remove foreign bodies or secretions from the 
ear. Syringing will be sufficient for all emergencies. 



DISEASES OF EYE, EAR, SKIN, AND GLANDS 257 

Probing with instruments is dangerous. Powder of some 
form is used to dry up the discharge. 

The throat is treated by local appHcations to cure the 
primary inflammation or congestion, and a Politzer bag 
is used to open the Eustachian tubes. This is accom- 
plished by closing the mouth and nostril, the nozzle of the 
apparatus being inserted into the other nostril. As the 
patient swallows, the end of the Eustachian tube is opened, 
the air is forced from the bag into the nose, and it then 
passes through the Eustachian tube into the mxiddlc ear. 
At times it is necessary for the surgeon to lance the ear- 
drum to relieve pain and allow the discharge to escape. 

When shaving the head for a mastoid operation in girls 
leave a lock of hair in front which can later be drawn 
down over the scar. At the time of operation it can be 
retained beneath adhesive plaster. If the physician per- 
mits, a shampoo before the operation will afford a great 
deal of comfort during the weeks the bandage is worn. 

SKIN DISEASES 

Anatomy. — The skin is composed of three layers: 
the epidermis, the true skin, and the subcutaneous or 
supporting tissue. 

The epidermis is the external layer and is without 
blood-vessels or nerves. It acts as a protecting membrane. 

The true skin Hes beneath the epidermis. It is exceed- 
ingly vascular and contains a meshwork of nerve filaments 
throughout its extent. The hair and sweat folHcles are 
situated in the true skin. 

Definitions. — Macules. — Small discolored areas of the 
skin without elevation. 

Papules. — Solid elevations of the skin, varying in size 

from a pin-head to a pea. 
17 



258 DISEASES OF CHILDREN FOR NURSES 

Vesicles. — Elevations containing a clear or opaque fluid. 

Blebs. — Large vesicles. 

Pustules. — Elevations containing pus. 

Scales. — Dry exfoliations of the epidermis. 

Crusts. — Brownish or yellowish masses of dried exuda- 
tion. 

Erythema. — A reddish blush to the skin. 

Miliaria (prickly heat) is caused by a blocking of the 
ducts leading from the sweat-glands. It produces small 
vesicles at the orifices of these ducts. 

Treatment. — Keep the bowels loose, apply a good toilet 
powder, and prevent irritation by placing silk or linen next 
to the skin. A saturated solution of bicarbonate of soda, 
frequently applied, will give much relief. 

Seborrhea is a disease usually involving the scalp; at 
times it is universal. It is characterized by the formation 
of dirty yellow crusts. The crusts should be removed by 
washing the scalp with warm water and soap and an oint- 
ment should be applied. 

Eczema is an inflammation of the true skin. 

It is caused by chapping of the skin surface from cold 
or discharges, such as running ears or coryza, and, reflexly, 
from the gastro-intestinal tract. 

Symptoms. — Intense burning and itching of the skin 
with redness and weeping of the surface affected. 

There are several varieties of eczema : 

Eczema vesiculosa; principal lesions are vesicles. 

Eczema papulosa; principal lesions are papules. 

Eczema pustulosa; principal lesions are pustules. 

Eczema rubrum, a raw weeping surface. 

Eczema intertrigo, caused by two moist surfaces rubbing 
together, such as the thighs. 

Treatment. — In eczema intertrigo bathe parts only once 



DISEASES OF EYE, EAR, SKIN, AND GLANDS 259 

a day with water; for all other cleansing processes use 
olive oil and dust parts with a 10 per cent, powder of 
balsam of Peru made with stearate of zinc. 

In the other forms of eczema the crusts must be re- 
moved as soon as they form, and the ointment thoroughly 
applied. 

To prevent children from scratching the inflamed skin 
pasteboard cuffs, well padded, are used. These are made 




Fig. 74- — Impetigo contagiosa (of one week's duration) in a girl ten years of age, crusting 
stage already reached; on chin and nose lesions have coalesced (Stelwagon). 

out of stiff pasteboard cut long enough to extend from the 
armpit to the wrist and wide enough to encircle the arm. 
They are held in place by a bandage. This prevents the 
bending of the elbow and renders it impossible for the 
child to scratch above the knees (see page 467). 

Furunculosis is characterized by the formation of 
numerous small abscesses or boils. 



26o DISEASES OF CHILDREN FOR NURSES 

Onychia is the name given to an inflammation at the 
root of the nail. 

Impetigo contagiosa is a contagious skin disease 
often transmitted through towels, and is characterized 
by several large, flat pustules which break early and form 
crusts. The disease is usually seen on the face. 

Urticaria or hives is characterized by red elevations 
which suddenly appear and vary from the size of a pea 
to that of a hand. They may be multiple. They itch 
intensely and are soon covered with scratch marks from 
the finger-nails. They last from one to two hours. Re- 
peated attacks are common. 

Treatment. — Apply some soothing lotion and give a 
laxative. 

Scabies, or the Itch. — A disease caused by a small 
"itch mite" or parasite buried under the epidermis. It 
is most often found between the fingers and the toes. 
The disease is characterized by intense itching. 

Tinea Circinata. — A ring-worm of the skin, character- 
ized by a circular irritation of the skin which fades toward 
the center. 

Tinea Tonsurans. — A ring-worm of the scalp. 

Lupus vulgaris is tuberculosis of the skin. 

Nevus or Birth-mark.— A collection of blood-vessels 
in the skin. They are characterized by a raised purphsh 
area. They should be excised if they cause disfiguration. 
■ Pediculosis Capitis, or Lice. — Small parasites infest- 
ing the hair. 

Pediculosis Pubis. — Small parasites infesting pubic hair. 

Congenital ichthyosis is a disease of the skin in which 
there is an overgrowth of the epidermis forming a horny 
surface resembling parchment. It may last through life. 

Nursing. — To obtain results in skin diseases it is neces- 



DISEASES OF EYE, EAR, SKIN, AND GLANDS 26 1 

sary to be patient and to apply the remedies thoroughly. 

All crusts should be immediately removed and the 
children prevented from scratching themselves. This 
may be accomplished by the use of cuffs (see page 467), 
or by tying the children down by the jacket (see page 467), 

Impetigo, scabies, tinea circinata, and tinea tonsurans 
are contagious; therefore, antiseptic precautions must be 
taken after treating such cases. 

DISEASES OF THE GLANDULAR SYSTEM 
Anatomy. — The lymphatic glands are arranged in 




Fig. 75- — Location of lymphatic glands of face and neck (Kerr). 

chains. They are situated along the lymphatic system. 
Their function is to act as filters, and keep poisonous 



262 DISEASES OF CHILDREN FOR NURSES 

substances and bacteria from entering the general circula- 
tion. The most important chains of the lymphatic gland 
in the body are the cervical, axillary, inguinal, bronchial, 
and mesenteric. They are located in the neck, armpit, 
groin, back of the bifurcation of the bronchi, and in the 
posterior part of the abdomen, respectively. 




Fig. 76. — Location of lymphatic glands (Kerr)v 

Ljrmphatism is the name applied to a general enlarge- 
ment of all the lymphatic structures in the body. It is 
due to an extreme susceptibility of the children affected 
to inflammation of the lymphoid tissues. The tonsils 
are enlarged, adenoids are present, and the chains of the 
lymphatic glands are swollen. 



DISEASES OF EYE, EAR, SKIN, AND GLANDS 263 

Adenitis is an inflammation of a lymphatic gland. 

Varieties. — Simple adenitis, acute or chronic ; tubercular ; 
syphilitic. 

Adenitis often occurs in the course of the acute infec- 
tious diseases, especially in measles and scarlet fever. 

Symptoms. — In simple acute adenitis there is a conges- 
tion and swelling of the glands. Suppuration is uncommon 
except after scarlet fever. An infected wound of the 
extremities may cause adenitis. Suppuration often takes 
place under such circumstances. 

Tubercular adenitis is common in childhood; suppura- 
tion occurs, producing sinuses. The tubercular glands 
are excised and curetted. 

Syphilitic glandular enlargements are occasionally seen 
in childhood. 

Hodgkin's disease is characterized by a general enlarge- 
ment of the Ivmphatic glands with progressive anemia, 
ending fatally. 



CHAPTER XII 
THE INFECTIOUS FEVERS 

CHARACTERISTICS OF FEVER 

Stages. — The febrile stages are invasion, jastigium.^ 
and defervescence. 

Invasion is the gradual rise until it reaches its maximum. 

Fastigium is the stage in which the temperature shows 
a tendency to reach again and again its highest point, 
although there may be marked variations. 

Defervescence is the gradual fall to normal. 

Terminations. — Crisis is a fall of temperature from its 
height to normal or subnormal within twenty-four hours. 

Lysis is a gradual fall to normal taking several days or 
a week. 

Hyperpyrexia is temperature above io6° F. 

Febrile Remissions. — All temperatures of fever show a 
diurnal remission, usually of one degree. The maximum 
is at 6 P. M. and the minimum at 6 A. M. 

Types of Fever. — Continued Fever. — The diurnal vari- 
ation is slight, from i° F. to 1.5° F. 

Remittent. — The diurnal variation is marked and the 
minimum temperature remains above the normal. 

Intermittent. — The diurnal variation is marked and the 
minimum temperature is normal or subnormal. 

Hectic. — Due to pus. High, irregular fever, with wide 
fluctuations, accompanied by sweats, chills, and pallor. 
264 



THE INFECTIOUS FEVERS 



265 



Fulse and Fever Ratio. — There are about ten extra 
beats of the pulse for every degree of fever. 

Simple continued fever without any definite cause is 
called jehricula. 



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Fig. 77. — Represents a continued fever. It is observed mosdy in erysipelas, acute 
tuberculosis, lobar pneumonia, and typhoid fever (Kerr). 

The period of incubation is the period elapsing between 
the entrance of the poison and the development of the 
symptoms of the disease. It varies considerably, being 



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Fig. 78. — Represents the remittent type. This is suggestive of one form of malaria, of 
tuberculosis (not acute), and supptiration (Kerr). 



influenced by the susceptibility of the patient and the 
virulence of the infection. For the following diseases 
the average period is: 

Typhoid fever — two to three weeks. 



266 



DISEASES OE CHILDREN FOR NURSES 



Measles — two weeks. 

Rotheln (German measles) — ten to twelve days. 
Scarlatina — a few hours to a week. 
Smallpox — one to two weeks. 



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Fig. 7Q> — Represents intermittent fever. The left hand half showing the quotidian type 
while the right hand half shows the tertian type. It is significant of malaria (Kerr). 



Erysipelas — three to seven days. 
Diphtheria — two to ten days. 
Varicella — ten to fifteen days. 



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Fig. 80. — Represents a hectic and suppurative fever type, which is generally accompanied 

with sweating (Kerr). 



Tetanus — a few days to two weeks. 
Mumps — two to three weeks. 

The date when rashes appear in various diseases is 
as follows: 



THE INFECTIOUS FEVERS 267 

Typhoid fever — seventh to ninth day. 

Smallpox — third or fourth day. 

Measles — third or fourth day. 

Scarlatina — first or second day. 

Rotheln — first or second day. 

Varicella — first day. 

Protection from future attacks conferred by various 
diseases is as follows: 

Typhoid fever — relapses are common; second attack 
are sometimes seen. 

Measles — second attacks rare. What are supposed to 
be second attacks are usually rotheln. 

Rotheln — second attacks rare. 

Smallpox — second attacks occasionally occur. 

Mumps — second attacks rare. 

The following diseases do not confer immunity. 

Erysipelas, diphtheria, malaria, influenza, and croupous 
pneumonia. 

An injections disease means one due to a specific micro- 
organism. 

A contagious disease is one which can be communicated 
by actual contact, either through the person or by infected 
clothing. 

A complication is a condition occurring in the course of 
a disease. 

A sequel appears after the attack. 

CEREBROSPINAL FEVER 

This disease is also called spotted fever and epidemic 
cerebrospinal meningitis. It is a specific infectious disease 
characterized by inflammation of the cerebrospinal men- 
inges (the membranes covering the brain and spinal cord) 



268 



DISEASES OF CHILDREN FOR NURSES 



and usually occurs in the winter and spring. The young 
are more susceptible than the old. The disease is now 
considered to be contagious. It is caused by a diplococcus. 

The mucous membrane lining the nose and pharynx 
is the portal of entry and dissemination of the disease. 

Symptoms. — Common Form. — The disease generally 
begins abruptly with a chill followed by vomiting and 
excruciating pain in the head, back, and limbs. The 
muscles of the head, neck, and back become rigid and 
contracted so that the head is bent backward and the 
back is straightened. In severe cases the body may be 
arched in a state of opisthotonos. The mind is soon 




Fig. 8 1 — Cerebrospinal meningitis: Tache cerebrale shown on left thigh (Ruhrah). 



affected, delirium is rarely absent, and in severe cases it is 
followed by stupor and coma. 

At first there is intense irritation of the whole nervous 
system, headache is severe and continuous, twitching of the 
muscles and actual convulsions are common, all the special 
senses are extremely acute, and there is pain on the slight- 
est movement, which often causes the child to cry out 
shrilly. Later, when the exudate becomes of sufficient 
amount to exert pressure, paralysis develops; it may be 



THE INFECTIOUS FEVERS 269 

localized, effect one side of the body, or one extremity. 
Blindness and deafness, disturbed speech, and mental 
defects are found in the protracted cases. When the 
finger is drawn over the skin a red line develops; this is 
called the tdche cerehrale (see Fig. 81). 

The temperature is irregular and indefinite in duration; 
ordinarily it ranges between 101° to 103° F. In some 
cases i'fis almost normal, while in others it is very high. 
The pulse is rapid and full, the bowels constipated, and 
there may be polyuria. 

The eruption is neither constant nor peculiar. In 
many cases a blotchy, purpuric rash appears over the 
entire body. Herpes facialis (fever blisters) are also fre- 
quently observed. In other cases urticaria or a roseolar 
or erythematous rash appears. 

The duration ranges from a few hours to several weeks. 

Treatm.ent. — Within the past two years this dreaded 
disease has been frequently cured by means of a seruni 
brought to the attention of the world through the work of 
Flexner and his associates at the Rockefeller Institute in 
New York. The disease is isolated in most cities under the 
Board of Health rules. 

Nursing.— In nursing the disease follows the same 
routine described under contagious cases (see page 318). 
Take every antiseptic precaution and spray the nose and 
throat frequently with some germicide. 

If a lumbar puncture is made by the physician, several 
sterile test-tubes properly stoppered with sterile cotton 
should be ready to receive the fluid. (For a description of 
Lumbar Puncture, see page 210). 

Flexner's serum should be kept on ice before use. 
At the time it is to be injected the bottle should be placed 



270 DISEASES OF CHILDREN FOR NURSES 

for five minutes in water at a temperature of 100° F. Do 
not use boiling water, as it coagulates the serum. 

When the bottle is opened its edge and neck should be 
thoroughly wiped with sterile gauze. 

The physician will introduce a hypodermic needle 
into the spinal canal, as in making a lumbar puncture. 
He will then fill the syringe, express all the air, and while a 
drop or two of the fluid is running from the syringe, attach 
it to the needle. For this reason it is better to have a 
needle which fits on the syringe, rather than one which 
screws on. This care is taken to avoid the introduction 
of air into the spinal canal. He will then inject the fluid 
very slowly. When the needle is withdrawn, adhesive 
plaster or a collodion dressing must be at hand to seal the 
wound. 

The child should be prepared for this minor operation in 
the same way as for a lumbar puncture. The syringe must 
be absolutely sterile. 

Injections are usually given every twenty-four hours. 

MALARIAL FEVER 

This is a specific non-contagious disease caused by the 
hematozoa of Laveran. It is characterized by splenic 
enlargement, by fever with periodic intermissions or re- 
missions, and by a tendency to extreme anemia. 

Etiology. — The exciting cause is the hematozoa of 
Laveran, and the mode of infection is by the bite of a 
mosquito which has previously sucked the blood of a 
malarial patient. All ages, from the newborn to the aged, 
are subject to malaria. 

Manifestations. — Malaria may manifest itself as in- 
termittent fever , remittent fever ^ or chronic malarial cachexia^ 



THE INFECTIOUS FEVERS 



271 



Pathology. — The Hematozoa. — A small, colorless ame- 
boid body enters the red blood-corpuscles, increases in 
size, and becomes pigmented from the coloring-matter of 
the corpuscles. When the red blood -corpuscle is destroyed 
the granules of pigment collect in the center of the organ- 
ism, which finally divides into a number of small hyaline 
bodies, each of which begins a new cycle of existence. 
The chills or paroxysms occur at the time these small 




Fig. 82. — Some of the principal forms assumed by the Plasmodium of tertian fever in the 
course of its cycle of development (after Thayer and Hewetson). 

bodies are thrown into the blood current after the blood- 
cells are destroyed, and are due to the production of a 
poison. 

The parasite of tertian intermittent fever requires 
forty-eight hours to complete its cycle of existence; there- 
fore, when a single group of these parasites exist in the 
blood a paroxysm occurs every other day. If, however, 
two groups co-exist and sporulate (the term given to the 
time when the organisms are thrown into the blood-cur- 
rent) on alternate days, a paroxysm occurs daily {quotidian 
intermittent fever). 

The parasite of the quartan intermittent fever requires 



272 



DISEASES OF CHILDREN FOR NURSES 



seventy two hours in which to develop and undergo 
sporulation; hence, a single group of these organisms in 
the blood excites a chill on every fourth day. When two 
groups co-exist a chill occurs on two successive days and 
is. followed by daily intermission. When three groups 
co-exist a chill occurs every day and there is quotidian 
intermittent fever again. The life-history of the parasite 
of remittent fever within the body is not definitely known. 
Its cycle of existence occupies from twenty-four to forty- 
eight hours. 

In advanced malaria the hlood shows a diminished 
number of red blood-corpuscles and a large quantity of 



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Fig. 83. — Tertian type of malarial fever. Male child of six years. Quinin begun at X 

(Kerr). 

free pigment. The spleen is greatly swollen and deeply 
pigmented. All the organs, including the brain, are 
discolored by this free pigment. 

Intermittent Malarial Fever. — Symptoms. — The char- 
acteristic features of this form of malaria are the intermit- 
tent type of fever, the enlargement of the spleen, the 
hematozoa in the blood, and the occurrence at regular 



THE INFECTIOUS FEVERS 2/3 

intervals of the paroxysms divided into three stages — 
the chill, the fever, and the sweat. 

Cold Stage. — There is malaise, headache, and great 
chilliness. The features are pinched, the lips are blue, 
and the surface of the body is cold and covered with 
"goose flesh." The rectal temperature is high — 104° F. 
to 105° F. Vomiting may occur. The chill lasts from a 
few minutes to an hour or two. 

Hot Stage. — The surface temperature gradually rises, 
the skin becomes hot, the face flushed, the eyes injected, 
and the pulse rapid and full. The temperature in the 
axilla may reach 106° F. to 107° F. The child complains 
of severe pain in the head, back, and limbs, and of thirst. 
The urine is scanty and dark colored. This stage usually 
lasts from one to five hours. 

Sweating Stage. — The fever gradually subsides, the pain 
grows less, free perspiration follows, and the child falls 
asleep from which he awakens feeling fairly well. 

Varieties. — When the disease occurs every day it is 
termed quotidian intermittent fever; every other day, 
tertian intermittent; every fourth day, quartan intermittent 
fever. 

Prognosis. — Always favorable. Even when no treat- 
ment is instituted the paroxysms gradually subside. 
Chronic malarial cachexia may develop. 

Remittent Malarial Fever or Estivo-autumnal 
Fever. — In temperate zones remittent fever is observed 
chiefly in the autumn. It is uncommon in children who 
live outside of malarial districts. 

Symptoms. — There is malaise with moderate chilliness 

followed by a continuous fever which daily remits. The 

maximum temperature ranges from 103° F. to 106° F., 
18 



2/4 DISEASES OF CHILDREN FOR NURSES 

and while this lasts the skin is hot, the face flushed, the 
eyes injected, the pulse full and strong, the urine scanty, 
and the patient complains of pain in the head, back, and 
limbs. Definite paroxysms may or may not be present. 
Delirium is sometimes noted, vomiting often occurs, and 
jaundice may appear from the destruction of the red blood- 
corpuscles and the liberation of their pigment. The spleen 
is enlarged and the hematozoa are found in the blood. 

Prognosis. — Favorable. The average duration is from 
one to three weeks. 

Chronic malarial cachexia is characterized by anemia, 
a sallow appearance to the skin, and splenic enlargement. 

Etiology. — It may result from repeated acute attacks of 
the disease or it may develop as a primary condition from 
slow infection. 

Symptoms. — The child is thin and pale, the complexion 
is of a dirty yellow or muddy hue, fever is often absent or 
if present, it is slight and irregular. The spleen is con- 
siderably enlarged. There is great weakness from the 
attending anemia. Headache and neuralgia are common 
symptoms. Hematuria is sometimes observed. 

Prognosis. — Guarded. With the spleen very large and 
extreme anemia the patients rarely recover. Malarial 
infection seems to predispose to certain cases of dys- 
entery, pneumonia, and amyloid degeneration of the 
viscera. 

Treatment. — As malarial fever is contracted by means 
of infection through mosquito bites, proper measures should 
be taken to protect children from the mosquitoes. Just 
as great care should be taken to prevent mosquitoes from 
biting children who have malaria, and in this way prevent- 
ing the spread of the disease. Quinin is a specific rem- 



THE INFECTIOUS FEVERS 



275 



edy, killing the hematozoa. The dose is from 5 to 10 
gr. a day in divided doses (four years), and in ordinary 
cases in older children is from 15 to 20 gr. a day in 
divided doses. The drug is given so that the last dose is 
taken two hours before the expected chill. The cold stage 
is treated with hot-water bottles and blankets, and the hot 
stage by sponging. 

SYPHILIS 

Syphilis is a communicable disease and may be ac- 
quired or hereditary. It is caused by the spirochaeta pallida. 

Syphilis is acquired usually from the mother of the child 
or from syphilitic wet-nurses. It follows the same course 
as syphilis in the adult and is divided into three stages. 
The first is characterized by a chancre, the second by a 
rash, and the third by a hone lesion and ulcerations. It is 
now considered contagious in all stages, but especially in 
the second stage. 

Hereditary syphilis is more common. When born the 
child at times has large blebs on the skin surfaces and 
scars develop around the lips called rhagades. 

Symptoms.^ — The Bones. — Epiphysitis, an inflammation 
of the ends of the bones, is present. Later in the disease 
chronic osteoperiostitis and syphilitic dactylitis are seen. 

The liver and the spleen are enlarged. 

The Respiratory Tract. — Pneumonia is common. Ulcers 
of the larynx are sometimes observed. 

Digestive Tract. — A chronic catarrh of the pharynx 
is present, causing "snuffles." 

The Organs of Special Senses. — Otitis media and 
interstitial keratitis are common. 



2^6 DISEASES OF CHILDREN FOR NURSES 

Nervous Symptoms. — Often absent, but there may be 
impairment of mentality. 

The children are weak and sickly and usually die 
young. 

If three months pass after a child is born from syphil- 
itic parents without the appearance of any characteristic 
symptoms, the child will, in all probability, escape. 




Fig. 84. — Hereditary syphilis: radiating fissures of the lips (after A. Fruhinsholz). 

Hutchinson' s Teeth. — If a child suffering from heredi- 
tary syphilis lives, the second or permanent teeth are 
characteristic (see Fig. 4). 

The teeth most frequently affected are the upper 
central incisors. They have a dull, opaque color and 
have a roughly rounded and stunted appearance. The 



THE INFECTIOUS FEVERS 2/7 

cutting edge of the tooth is narrower than its neck. Over 
the tips of these stunted and conic teeth the enamel is 
irregular and forms a semilunar notch. 

The Wassermann reaction is a test made with blood 
from an individual suspected of having syphilis. It is 
rehable in about 80 to 90 per cent, of cases. 

The physician will take from 4 to 8 c.c. of blood from 
a vein, or less from a stab of the finger, toe, or ear, and 
let it stand at the room temperature for one hour until 
firmly clotted, then it should be put on ice. Be sure and 
label the tube and reference card, as all blood specimens 
look the same. If properly taken and kept the specimen 
will not disintegrate for four or five days. 

The test consists in mixing the serum of this specimen 
with a syphilitic antigen, which is a solution of a liver from 
a syphilitic fetus which has shown the Spirochaeta pallida 
(the germ that produces syphilis). To this is added 
blood-serum from a guinea-pig, and the whole is placed 
in an incubator for three-quarters of an hour at 37° C. 

After this, rabbit's serum, which has been immunized 
to red sheep cells, is added, followed by a solution of 
washed red blood cells from a sheep, and the tube shaken. 

The whole is again incubated for one to one and a half 
hours at 37° C. If the test is positive, there is no hemo- 
lysis; that is, the upper part of the tube is clear and the 
red corpuscles are precipitated in the lower part. 

If it is negative, there is complete hemolysis; no cor- 
puscles are precipitated in bottom of tube. 

Complement fixation is the same test, except a gono- 
coccus antigen is used instead of syphilitic liver. 

Treatment. — The treatment of both hereditary and 
acquired syphilis consists in giving mercury. This, in 



278 DISEASES OF CHILDREN FOR NURSES 

infants, is given in the form of ointments. Great care 
must be taken by the nurse to avoid contamination in 
handling syphihs. 

Salvarsan, a preparation of arsenic, discovered by 
Ehrlich, seems to give excellent results. It is injected 
intravenously or intermuscularly. 

TETANUS OR LOCKJAW 

An acute infectious disease excited by the tetanus 
bacillus and characterized by paiaful tonic spasms of the 
voluntary muscles. 

The bacillus gains an entrance to the system through 
some wound. Lacerated and punctured wounds, burns, 
and frost-bites are most likely to become infected. Stables 
seem to be the breeding ground for the bacillus. 

Sjmiptoms. — The disease begins with rigidity in the 
muscles of the neck and lower jaw, by degrees the mus- 
cles of the back, abdomen, and extremities are similarly 
involved. The face has a peculiar expression, the brow 
is wrinkled, the corners of the mouth are drawn up (the 
sardonic grin) and the jaws are tightly closed (trismus). 
The body may become arched in a position of opisthot- 
onos. There is extreme hyperesthesia, and the slightest 
touch causes an increase in the spasm which is attended 
by severe pain. If the respiratory muscles are involved 
there is intense dyspnea. The temperature usually re- 
mains normal until just before death, when it may rise 
to 107° F. or more. The mind is clear to the end. 

The duration is from a few days to several weeks. 
Death occurs in nearly every case. 

Tetanus occurs sometimes in the neivly born from 
infection of the umbilical cord. 



THE INFECTIOUS FEVERS 2/9 

Treatment. — There is an antitoxin for tetanus which 
is injected into the system. 

HYDROPHOBIA OR RABIES 

A disease of dogs which at times is communicated to 
children through a bite of an animal suffering from rabies. 
It takes about six weeks for the disease to develop after 
the wound is received. 

Symptoms. — These consist principally of paralysis of 
the muscles of the throat, which prevents swallowing. 
There is fever, and convulsions are present. 

Treatment. — All dog bites should be immediately 
washed with antiseptic solutions and a wet bichlorid 
dressing applied. At the present time cauterization has 
been discontinued, the bite being treated as an open 
wound. If the dog is known to have had rabies, treatment 
by the Pasteur method will prevent the child from develop- 
ing the disease. Pasteur institutes exist in New York 
and Chicago. The Boards of Health of some of the 
larger cities furnish the serum. The treatment, according 
to this method, consists of hypodermic injections of the 
serum extending over a period of several weeks. 

TYPHUS FEVER (BRILL^S DISEASE) 

An infectious disease which is rarely seen at present 
except in isolated instances. Formerly it was one of the 
scourges of the world. 

When it was found that it was spread by overcrowding 
and filth, and measures were instituted to improve the 
hygienic and sanitary conditions of people Hving under 
such conditions, the epidemics of the disease were con- 
trolled. 



28o DISEASES OF CHILDREN FOR NURSES 

Brill, of New York, has lately recognized that a series 
of symptoms occurring in children to which the name 
^'Brill's disease" had been applied is, in reality, a sporadic 
form of typhus fever. 

Symptoms. — Beginning with the usual prodromes, the 
fever rises rapidly to 103° or 104° F. On the fifth or 
sixth day a rash appears which does not disappear on 
pressure, and which persists until the crisis, when it 
rapidly fades. The children are much prostrated, with 
severe headache, but no abdominal symptoms. Consti- 
pation is usually marked. After persisting for twelve to 
fifteen days, the fever usually falls by crisis, and there is a 
speedy recovery. 

There is a negative. Widal reaction with typhoid organ- 
isms. The disease is rarely fatal and does not spread to 
other patients in the ward or in the home. 

NURSING IN THE ACUTE INFECTIOUS DISEASES 

The room should be kept at an even temperature; it 
should be well lighted and ventilated. Bathing should 
be thorough. 

The clothing should be of a light woolen texture. 
Sleep should be encouraged, the urine should be examined 
routinely, and the temperature, pulse, and respirations 
taken every three hours where there is fever. 

The nurse should roll up her sleeves when nursing an 
infectious disease. 

Care should be taken by the nurse to prevent the infec- 
tion of herself. All antiseptic precautions should be 
employed In malaria the child should be protected 
against mosquitoes. 

She should avoid all possibility of being scratched or 



THE INFECTIOUS FEVERS 28 1 

bitten in hydrophobia. This may occur if it is necessary 
to feed by gavage. 

The feedings should be Hquid. In tetanus it may be 
necessary to feed through a catheter placed in the mouth 
or nose; it may be necessary to chloroform the child while 
doing this. 

In syphilis avoid contagion, and when applying mer- 
curial ointment, to prevent irritation of skin, select a new 
place each day. For example, the abdomen, right and 
left axillae, and the right and left thighs can be utilized 
in rotation. 

A glass rod is the best means of applying mercurial 
ointment; i dram is used, and is rubbed in for a half hour. 



CHAPTER XIII 
TYPHOID FEVER 

Typhoid fever is an acute infectious fever due to the 
typhoid bacillus or bacillus of Eberth. 

The disease is especially characterized by pathologic 
changes in the lymph-follicles of the intestines and par- 
ticularly of Peyer's patches, by changes in the mesenteric 
glands, and by an enlargement of the spleen. The lesions 
in the intestines and the mesenteric glands are ulcerative 
in character. 

Typhoid fever is recognizable in the writings of the 
ancients four hundred years before Christ, and ever since 
that period epidemics of this disease have been constantly 
recorded in medical history. The causes for the frequent 
epidemics are better understood when it is known that the 
typhoid bacillus shows great resisting powers. They have 
remained alive for three months in distilled water, and 
when buried in the upper layer of the soil they will retain 
their vitality for six months. 

Dissemination of the Disease. — The method by 
which the typhoid bacillus spreads the disease is well 
understood. The stools of a person suffering from the 
disease are filled with the germs. Unless these stools are 
covered with some solution like carbolic acid, ■2V5 bichlorid 
of mercury, 2- oVo"J ^^ chlorinate of lime, of equal strength, 
they pass with the sewage to the nearest water-course. 
Once in the stream they may pollute an oyster bed or they 
282 



TYPHOID FEVER 283 

may be contained in the water used to sprinkle green 
vegetables. By far the greatest danger is in swallowing the 
bacilli in drinking water. Milk may be contaminated by 
water containing the bacillus. 

The distances they travel, at times, is almost incredible. 
Miles down a stream an epidemic will arise traceable to 
one case at its source. A case occurring in the fall of the 
year can produce typhoid after the spring thaws, if the 
stools are carelessly deposited on the upper surface of the 
soil. 

The relatively infrequent communication of typhoid 
fever to physicians and nurses is explained by the fact that 
the contagion escapes from the child in the stools alone, 
and as these are promptly disposed of, the chances of 
dissemination of the poison are few. Carelessness in the 
disposition of these discharges, such as permitting them to 
dry upon the linen and in this manner allowing the bacillus 
to pass into the air of the room, at times occasions the 
infection of the nurse, the physician, and others attending 
a typhoid case. 

Age. — Typhoid fever is seen most often during adoles- 
cence and in adult life before thirty years of age, although 
it occurs frequently in childhood. It is rare before two 
years of age. In the young the duration of the disease is 
short, and the prognosis very favorable. 

Sex. — Typhoid fever seems to be more prevalent among 
boys than among girls, probably because of their more 
frequent exposure rather than greater susceptibility. 

Season. — Typhoid fever is more common in the late 
summer and in the early autumn months than at any other 
time of the year; hence one of the- names for typhoid is 
autumnal jever. 



284 DISEASES OE CHILDREN EOR NURSES 

Morbid Anatomy. — The principal lesions in typhoid 
fever are in Peyer's patches in the ileum (the lowermost 
portion of the small intestines). Peyefs patches are a 
collection of lymphatic glands in the walls of the intestines 
and are from one to three inches in length. The typhoid 
bacilli implant themselves in these glands and cause an 
inflammation. The Peyer's patch becomes swollen and 
the superficial tissue sloughs off, leaving a raw, ulcerating 
surface. This is called a typhoid ulcer. These ulcers may 
be very small, from an eighth to a quarter of an inch in 
diameter. More often there is a large, elliptic ulcer, a 
whole Peyer's patch being involved. At times by the 
union of one or more ulcers much larger ones are formed, 
especially at the lower end of the bowel. The borders of 
the ulcers are raised, the floor of the ulcer is usually the 
submucous, or muscular coat of the bowel. (The bowel 
has four coats, the mucous, the submucous, the muscular, 
and the peritoneal.) If the ulcer eats through all these 
coats there is a perforation of the bowel. The discharge 
of the contents of the intestines through the perforation 
iQto the peritoneal cavity is often followed by a fatal 
peritonitis. More commonly the ulcer heals before the 
bowel is perforated, and the patient recovers, but the 
normal glandular substance is never restored at the seat 
of the ulcer. 

At autopsies ulcers are discovered at different stages of 
healing, sometimes they are all healed with the exception 
of the single fatal spot, which has become the seat of 
perforation. The large intestines are also invaded at 
times; perhaps in about one-third of the cases perforation 
may take place here and also in the appendix where the 
process occasionally extends. Similar infiltration of the 



TYPHOID FEVER 285 

lymph nodules and the lymph cords of the mesenteric 
glands and of the spleen occurs, contributmg to the enlarge- 
ment of these organs. In the spleen it is associated with 
active congestion which causes a further enlargement, 
generally recognizable during life. There has even been 
known to be a rupture of this organ. Changes in the 
liver, kidneys, and in the respiratory organs are often 
found. Hypostatic congestion of the lungs is a frequent 
complication. Thrombosis of the veins, especially of the 
femoral, causes the not very rare symptom of milk-leg. 
Endocarditis is sometimes found. Notwithstanding the 
intensity of the nervous symptoms in some cases, menin- 
gitis is rarely met with. Abscess of the parotid gland is a 
familiar complication. 

Characteristics of Typhoid Fever in Children. — ■ 
During childhood the disease is of shorter duration, milder 
course, has fewer complications, and has a lower mortality 
than in adult life. 

The onset is more sudden, fever, vomiting, and prostra- 
tion being seen as often as slow insidious beginnings. 
Constipation is more frequent than diarrhea, tympanites 
is not marked, and the eruption is less constant in child- 
hood. Nervous symptoms are not as frequently found 
as in adults; hemorrhage and perforation are also met 
less often. Noma is sometimes a complication. Death 
rarely occurs in uncomplicated cases. After ten years of 
age the symptoms are similar to those seen in adult life. 

Symptoms and Course. — A certain period of incubation 
is necessary after the successful implantation of the bacilli 
before typhoid fever arises. This varies from a few days 
to two weeks and even longer in some cases. The period 
of incubation may be without symptoms, but a sense of 



2S6 DISEASES OF CHILDREN FOR NURSES 

weariness and indisposition to play are usually present. 
The latter often can be overcome by force of will. A 
want of appetite and a slight coating of the tongue are not 
infrequent. In older children the disease itself usually 
sets in gradually and often is quite advanced before it is 
suspected; indeed, at times well advanced, constituting the 
so-called walking typhoid. In children under ten years of 
age the onset is less gradual. 

Symptoms of the Attack. — There may be headache, 
anorexia, a furred tongue, nausea, chilliness, but seldom a 
decided rigor. The disease may be ushered in by pain in 
the back or leg muscles and there may be nosebleed {epi- 
staxis). In older children there may be a looseness of the 
bowels. There is continuously a slight fever and the 
child feels wretched. The fever and discomfort increase 
and finally the child goes to bed. The tendency to loose- 
ness of the bowels and epistaxis justify a strong suspicion 
of the existence of typhoid fever. Yet one or both are 
frequently absent, and in younger children constipation 
is more often seen than diarrhea. The abdomen soon 
becomes slightly distended and pressure on the right iliac 
fossa elicits tenderness with gurglingo 

Rash. — Usually about the eighth day, rarely later and 
sometimes a little earlier, the rose-colored spots make their 
appearance on the skin of the abdomen and chest and at 
times elsewhere on the body. They are mostly bright 
red in color, disappear on pressure, and reappear instantly. 
They are very slightly, if at all, raised. Their number 
varies greatly. Sometimes they are very numerous, but 
more often but five to ten are discovered. 

Herpes are very rarely seen, in contradistinction to 
pneumonia. 



TYPHOID FEVER 



287 



The ]en)er is at once the most important and the most 
characteristic symptom, and from the temperature alone a 
diagnosis can be suspected. 

Initial Stage. — During the first week of 'the fever there 
will be found a peculiar tide-like evening rise and morning 
fall, the temperature of each morning and evening being 
from one and a half to three degrees higher than that of 
the morning and evening previous. 

The jastigium is the stage when, the fever again and 
again reaches the highest point. At the end of a week 
the height of the fever is reached and then it continues 
with but little variation, the evening rise and the morning 
fall still being characteristic, but the remission being less 
than that seen at the onset — from a half to two degrees 
being found. It is during this period that the maximum 
temperatures are found; often 105° F. or a little above 
are noted. A temperature of 106° F. is frequently fol- 
lowed by recovery, and while temperatures of 107° F., 
108° F., and even 109° F. are sometimes seen, they 
usually result fatally. 

The fastigium is succeeded by a third stage or stage of 
decline in which the reverse of the initial stage is shown 
by an evening temperature lower than that of the previous 
evening and the morning temperature lower than that of 
the previous morning, but the evening temperature still 
higher than the morning temperature of the same day. 
This decline continues until the normal is reached, and at 
times from one to two weeks are consumed before this is 
attained. The duration of the fever in children, however, 
is usually shorter than in adult life. 

Sudden falls of a decided character may occur in conse- 
quence of hemorrhage from the bowels or even from the 



288 



DISEASES OF CHILDREN FOR NURSES 



nose, or from collapse after perforation of the bowels. 
Sudden rises are produced by indiscretions in diet or by 
the supervention of some acute inflammatory condition, 
such as pneumonia. The skin is usually dry, although 
profuse sweating sometimes occurs most frequently after 
a bath. Children frequently have higher temperatures 
than adults. 

The pulse is not very frequent, 90 to 120 is the usual 
average. In grave cases it maintains a frequency of 140. 





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Fig. 8s — Chart of the temperature ( ) and pulse ( ) in typhoid fever of moderate 

severity in a male child five years old (Kerr). 



The pulse is often dicrotic (see page 175). The breath- 
ing rate commonly advances with the rate of the pulse. 
The heart-sounds at first are normal, but gradually grow 
less distinct as the prostration increases. 

As the disease advances the tongue, previously furred, 
tends to become dry and brown, clearing at the edges, 
however, and also at the tip as the case improves. In 
severe cases, especially, if the mouth is not kept clean, 
sordes form on the teeth, stomatitis sets in, and the lips 
are covered with black crusts. 



TYPHOID FEVER 289 

Diarrhea, if present, is rarely troublesome. The stools 
are apt to be grayish-yellow and of about the consistency 
and frequently likened to pea soup. 

Hemorrhage from the bowel is always a serious com- 
plication, but by no means fatal, though large quantities 
of blood are sometimes discharged. Very rarely a patient 
will bleed to death. Following the hemorrhage there 
will be a marked fall in the temperature and a pallor and a 
faintness such as is common to large hemorrhages else- 
where. 

Perforation is suspected when there is a sudden pain 
in the side with spreading tenderness and vomiting. The 
temperature falls and the pulse becomes more rapid. If 
these symptoms occur during the course of typhoid the 
physician should be immediately informed. 

Tympanites or distention of the abdomen in a mild 
degree is at times present in children, but not so often as in 
adults. The accumulation of gas is commonly ascribed 
to atony of the bowel. 

Delirium is rare in childhood. 

A tendency to drowsiness or even stupor is present, and 
from this the name of the disease is suggested. Muscular 
tremor is a symptom in severe cases. Carphalogia or 
picking at imaginary objects is sometimes present and is 
merely a symptom of the typhoid state; it is not necessarily 
of fatal import, as is so often thought by the laity. When 
this condition, known as the typhoid state, sets in the 
tongue becomes dry, brown, and fissured. 

Slight cough usually sets in as the disease advances, 

due to a hypostatic congestion of the lungs. This can be 

relieved by frequently changing the position of the child 

in bed. 

19 



290 DISEASES OF CHILDREN FOR NURSES 

The Spleen is always enlarged, reaching in the first half 
of the second week two or three times its normal size. It 
then gradually diminishes. Tenderness may accompany 
the enlargement. 

The urine in typhoid cases is always dark hued and 
concentrated, with correspondingly high specific gravity. 
Often when the fever is high there may be a slight albu- 
minuria. If there is a nephritis present there will be 
casts in addition to the albumin. 

The hlood in typhoid fever shows a slight diminution 
in the white blood-corpuscles in contradistinction to pneu- 
monia where they are greatly increased. There is also a 
reduction in the red blood-corpuscles and the hemoglobin, 
according to the severity of the case. 

The Widal reaction depends upon the ability of the 
blood from a typhoid patient to agglutinate a pure culture 
of typhoid bacilli. It is positive in about 95 per cent, of 
all cases of typhoid, so it is practically a sure sign of the 
disease. 

The diazo reaction is a test made with the urine. 

Sequelae. — Insanity in the form of acute mania some- 
times occurs. Aphasia and chorea have been reported. 
Phthisis, post-typhoid bone lesions and typhoid spine 
(a severe pain in the back aggravated by motion) follow 
the disease. As a rule sequelse are uncommon in children. 

Relapses often occur following upon the relaxation of 
diet. The symptoms of a relapse are those of the primary 
disease, excepting that the symptoms are less severe, the 
duration shorter, and recovery the rule. Relapses may be 
multiple. 

Recrudescence is a simple return of fever, also often 
induced by lapses in diet. 



TYPHOID FEVER 29 1 

Prognosis. — In children under fifteen recovery almost 
invariably takes place. Hemorrhage and perforation 
occur less often than in the adult. 

A mistake is often made in using the term typhoid 
pneumonia^ meaning typhoid fever complicated by pneu- 
monia. Typhoid pneumonia means pneumonia with 
typhoid symptoms, such as the brown, dry tongue, delir- 
ium, twitching of the tendons, and picking at the bed- 
clothes. These occur in fevers when patients are ex- 
hausted, and are not seen in typhoid fever alone. In 
typhoid pneumonia^ typhoid fever does not exist. If the 
two are present at the same time use the title typhoid and 
pneumonia. 

Vaccination Against Typhoid. — This prophylactic 
measure has proved efficient in almost every case where 
proper inoculation has been made. It is important that 
the nurse in training and in active practice should be 
vaccinated. 

The method consists in giving hypodermically a cul- 
ture of typhoid bacilli which has been rendered prac- 
tically non-virulent through long cultivation of a single 
strain, and then killed by heat. 

The first inoculation consists of 500,000,000 dead bac- 
teria in salt solution. The second and third doses, each 
given at intervals of ten days, contain 1,000,000,000 dead 
bacilli. 

The best time to give the injection is in the afternoon, 
so that its effects will wear off during the night. The 
immediate effect of the inoculation is a smarting pain last- 
ing for only a minute or two. Nothing further is noted 
until four or five hours later, when headache and malaise 
may develop, and at the site of the inoculation a red and 



292 DISEASES OF CHILDREN FOR NURSES 

tender area the size of the palm of the hand. The 
headache and other symptoms are rarely severe enough to 
interfere with sleep, and by next morning all symptoms 
usually have disappeared. 

The introduction of these dead bacteria causes the 
blood to develop antibodies similar to those formed in 
true typhoid. 

We have the same reaction taking place that would 
follow the presence of living typhoid bacilli, and the same 
units of defence are organized. As the bacilli are dead, 
they do no harm, but the resistance developed by their 
introduction lasts over a period of several years, during 
which time any typhoid bacillus which should lodge in 
the body would be immediately destroyed. 

This immunity to typhoid lasts about three years, at 
the end of which time fresh vaccination is advisable. 

Treatment and Nursing. — Absolute rest and restriction 
of diet are essential. Many physicians use a liquid diet, 
others a more liberal one. It is usually governed by the 
amount of emaciation and tympanites. 

The treatment of typhoid fever by graduated haihs is 
far better than by any other method. It not only reduces 
the temperature, but controls the delirium, the diarrhea, 
and keeps the mouth and tongue in good condition. It 
also lessens the severity of every symptom. The method 
of giving these baths is described on page 429). The 
effect of the bath on the temperature varies with the 
stage of the disease, it being frequently the case in the 
first week that the fall in temperature is less than one 
degree; in the second and third week, however, the fall 
will be from one to three degrees. In addition to lowering 
the temperature the immediate effect of the baths is to add 
strength to the heart and volume to the pulse (Holt). 



TYPHOID FEVER 293 

Contra-indications . — Practically the only con tra-indica- 
tions to this plan of treatment are: (i) When there is an 
almost absolute pulselessness with a blue, cyanosed 
appearance of the skin occurring while giving the tub, in 
which case the child should be immediately removed, put 
to bed, and hot-water bags applied to the extremities 
and whiskey given. (2) Hemorrhage. (3) Perforation. 
None of the complications excepting hemorrhage from 
the bowel and perforation are allowed to interfere with 
the carrying out of this treatment. The reason they are 
discontinued in hemorrhage is the fear that the necessary 
movements in the bath would excite further bleeding; and 
in perforation, to avoid the danger of unnecessary contam- 
ination of the peritoneum with feces. Delirium is con- 
trolled by a soothing voice and touch in conjunction with 
the bromids. 

Constipation should be relieved by the enemas alone. 

Hemorrhage from the bowel should be treated by 
absolute rest, cold to the abdomen, the food should be 
reduced to a minimum, and be of the mildest character. 
In severe cases the foot of the bed can be raised. The 
physician should be immediately notified. 

Perforation, — Symptoms of perforation, such as spread- 
ing tenderness, sudden pain in the side and vomiting, 
demand absolute quiet and the immediate notification of 
the physician. 

Tympanitic distention may be relieved by the careful 
passage of the rectal tube, and the pain relieved by tur- 
pentine stupes. 

One of the dangers of protracted cases is bed-sores. 
These can generally be averted by careful attention to 
cleanliness, by thoroughly drying the patient after washing, 



294 DISEASES OF CHILDREN FOR NURSES 

by removing all traces of urine or other discharges, and 
by sponging the patient daily with alcohol or whisky. 
Above all, the position in bed should be changed frequently 
and all inequalities in the bed-clothes should be kept 
smoothed out, while the bed should be kept clear of crumbs 
and other particles of food. Should a sore appear, anti- 
septic dressings should be applied and the part relieved 
from pressure by an air-cushion.. 

Convalescence.^ln no disease is watchfulness during 
convalescence more important. Relapses and the per- 
foration of an ulcer may occur during this period. The 
ulcers are not necessarily healed when the temperature 
reaches the normal. Therefore, absolute rest and a liquid 
diet should be kept up for at least ten days after the tem- 
perature has reached normal. The hair is very apt to fall 
out and, therefore, should be cut short. By no means is it 
necessary to shave the head. 

Prophylaxis; — When typhoid is epidemic all drinking- 
water should be boiled for one-half hour before using. 
Since the contagion of typhoid fever resides solely in the 
stools, vomited matter, urine, and other discharges from 
the body, it is important that these should be thoroughly 
and properly disinfected, also that the linen which has 
been in the least degree soiled by them should be imme- 
diately removed and sterilized. 

Stools may be disinfected in the following manner: 
Place in the bed-pan,- before using, a small quantity of car- 
bolic acid solution, i : 20, or chlorinated lime of the same 
strength. Cover the evacuation with another quantity of 
the disinfectant, mix thoroughly, stand aside for one-half 
hour, then empty the whole into the water-closet hopper. 
Then thoroughly rinse out the vessel with disinfectant 



TYPHOID FEVER 295 

solution and hot water. Linen may be immersed in 
carbolic acid, i : 20, until boiled. Boiling for half an 
hour disinfects it. 

After the bowels have been moved the buttocks and 
anus of the patient should be thoroughly washed with i : 
40 carbolic acid or bichlorid, i to 2000, followed by hot 
water and soap. 

Door-knobs or parts of the door touched with the soiled 
hands should be washed with the same disinfectants, 
since drying of the fecal matter causes it to disseminate 
and gives rise to a source of infection. 

The nurse should wash her own hands with soap and 
water and then rinse them in a solution of bichlorid. It is 
by soiled hands or floating bacteria from dried feces that 
nurses are infected. 

Where tub-bathing is employed, it is possible that the 
water of the bath that has been used several times may be a 
source of infection. The nurse should, therefore, wash 
her hands after tubbing a patient, and watchful care 
should be exercised not to carry them to the mouth during 
the bath. 

After death or discharge of the patient the mattress, 
which should be well protected during use by a rubber 
sheet, should be thoroughly aired. The rubber sheet 
itself should be washed in carbolic acid, rinsed in cold 
water, and dried in the open air. 



CHAPTER XIV 
TUBERCULOSIS 

Tuberculosis is an infectious, communicable disease 
due to the bacillus tuberculosis of Koch. It is a disease 
that may occur at any time of life, most frequently in 
childhood and between the ages of twenty and thirty. It 
may be local or general and may involve any organ and 
almost any structure of the body. 

The predisposing causes to tuberculosis are divided 
into general and local. 

General predisposition to the disease may be inherited 
directly from the parents, who have themselves suffered 
from tuberculosis, or from those who, in consequence of 
syphilis, alcoholism, or any other constitutional vice, have 
transmitted a feeble constitution to their children. Actual 
congenital tuberculosis is rare; that is, a child is rarely 
bom with tuberculosis, although cases are som.etimes 
seen. The surroundings in which a child is reared 
plays an important part in the general predisposition 
to tuberculosis, cramped quarters and exposure being the 
chief causes. In childhood marasmus, intestinal diseases, 
in fact any debilitating general or local disease, may 
predispose to tuberculosis. 

A local predisposition is created by any diseased condi- 
tion of the mucous membranes or organs most exposed 
to the infection. The most important are repeated attacks 
of bronchitis, bronchopneumonia or pleurisy, and chronic 
296 



TUBERCULOSIS 29/ 

catarrhal inflammations of the nose and pharynx so 
frequently associated with enlarged tonsils or adenoid 
growths of the pharynx. 

The role played by other diseases in the development 
of tuberculosis is important and, until recently, little under- 
stood. In a very large number of cases tuberculosis 
develops as a sequel of one of the acute infectious dis- 
eases, particularly measles, pertussis (whooping-cough), or 
epidemic influenza. In such cases there probably has 
existed a previously latent tuberculosis, usually an involve- 
ment of the bronchial lymph-nodes. An acute disease, 
like pertussis, lowers the general vitality of the body and 
gives the tubercular process a chance to light up. As long 
as the constitution of the child is robust and the resisting 
powers of the tissues are up to par there is slight danger of 
contracting any form of tuberculosis. It is when the 
resisting powers of the tissues are faulty that the bacilli 
gain a foothold, and this may be in the mucous membrane 
of the throat, lungs, or bowel. The bacilli are taken up 
by the lymphatics and carried to the nearest lymph-gland, 
where they are arrested. The glands involved may be 
the cervical lymph-glands or the bronchial lymph-glands 
which are back of the bifurcation of the bronchi and 
receive the lymphatics from the lungs; or the mesenteric 
lymph-glands which are retroperitoneal (behind the 
abdominal viscera) may be involved. When the bacillus 
enters one of these glands it starts an inflammation which, 
if allowed to run its course, will be the typical inflammation 
produced by the tubercle bacillus; namely — congestion, 
swelling, cell proliferation, and caseation. Or if the 
vitality of the body is regained this process may be arrested 
at any point and the product of the inflammation will 



298 DISEASES OF CHILDREN FOR NURSES 

become encapsulated by a wall of fibrous tissue (the way a 
tubercular lesion is cured), in which condition they may 
lie latent in the body for an indefinite number of years 
and possibly for a life-time. Tubercular cervical adenitis 
is frequently seen in the hospital wards ; tubercular lymph- 
glands, both bronchial and mesenteric, are met with as 
often in the autopsy-room. 

If for any reason the vitality of the part is not strong 
enough to resist the tubercular inflammation, or if some 
intercurrent disease lowers the vitality sufiiciently to 
permit a lighting-up of the old tubercular inflammation, 
sooner or later these lymph-glands will caseate and rupture. 
In the cervical glands such a condition leads to the sinuses 
of the neck so frequently seen, while in the bronchial 
glands such a condition leads to a tubercular infection of 
the lungs known as phthisis. In the mesenteric glands 
the rupture leads to abscess formation, peritonitis, or 
tubercular enteritis. 

Any structure of the body may be involved by the tu- 
bercle bacillus. When the spine is affected there is Pott's 
disease, when the bones and joints are affected there is 
tubercular osteomyelitis, coxalgia, and other surgical con- 
ditions. The liver, spleen, pleura, kidneys, and all other 
organs may be involved, usually secondarily. 

The bacillus does not always take the above course. It 
may enter the lungs directly by inhalation and set up a 
tubercular lesion, or it may be swallowed in the milk and 
meat from tubercular cattle. 

In young children under two years of age the lung is the 
part of the body usually affected; beginning with the 
second year tubercular meningitis is more frequently 
found; and after the third year tuberculosis of the bones, 



TUBERCULOSIS 299 

of the cervical and mesenteric lymph-glands, and of the 
peritoneum and intestines become more frequent and are 
seen throughout childhood. 

That the disease is communicable is proved by large 
numbers of individual cases in which a person closely 
associated with the tubercular patient has contracted the 
disease and died. It is sometimes hard to trace the origin 
of a given case of tuberculosis on account of its tendency 
to lie latent for so long a period. 

In addition to the above predisposing causes residence 
in a low, damp, and badly drained locality, and physique 
contribute to the tendency toward developing tuberculosis. 

The physique of the child is important. Children who 
suffer with tuberculosis of the lungs usually have a flat 
chest with prominent shoulder-blades and a narrow angle 
of the ribs at the lower border of the anterior portion of the 
chest. This is called the phthisic chest. It seems to 
predispose to tuberculosis of the lungs on account of the 
poor expansion of the lungs which results from such a 
formation. Many children have phthisic chests who are 
not suffering from the disease. Phthisis is the name ap- 
plied to tuberculosis of the lungs. 

The varieties of tuberculosis seen in children are 
tuberculous bronchopneumonia, miliary tuberculosis, 
tuberculosis of the bronchial lymph-glands, tubercular 
meningitis, and tubercular bone and joint diseases. 

TUBERCULOUS BRONCHOPNEUMONIA 

Pathology. — If the tubercle bacillus does not gain 
access to the lungs from the rupture of the bronchial 
lymph-node the bacillus entering the respiratory tract 
through the inspired air lodges in the terminal bronchioles 



300 DISEASES OF CHILDREN FOR NURSES 

and excites a proliferation or overgrowth of the fixed cells. 
The new cells are termed epithelioid and frequently 
contain bacilli. Giant-cells are often formed by a fusion 
or overgrowth of these cells. This aggregation of new 
cells acts as an irritant and is soon surrounded by a wall 
of leukocytes, the whole forming a gray, translucent mass, 
the so-called gray tubercle. In a short time the bacillus 
excites a necrosis or softening which starts in the center, 
spreads to the periphery and converts the tubercle into a 
yellow, cheesy mass called the yellow tubercle. The degen- 
erated tubercles fuse and form the uniform cheesy masses 
commonly observed at the autopsies. At this stage one 
or two things may occur. Either the mass may soften, 
break into a bronchial tube, and leave behind a cavity 
with ulcerating walls, or it may become encapsulated by 
an overgrowth of connective tissue and later calcify. 
In addition to the tubercular process other changes are 
noted. The lung tissue in the neighborhood of the tuber- 
culous deposits is the seat of a true bronchopneumonia 
inflammation, the connective tissue is always more or 
less proliferated, the bronchial tubes are inflamed, and 
the pleura over the affected area is always adherent. 

In injants the disease resembles marasmus, and it is 
very hard to distinguish the two conditions. 

In older children the disease follows one of three courses : 
namely, a rapid, acute course, a subacute course, and a 
chronic course. 

Symptoms. — In the acute form the disease resembles 
bronchopneumonia. The characteristic symptoms of 
phthisis are absent. The temperature remains high, 
without intermission, and there is a gradual loss of flesh 
and strength. Death results in every case. 



TUBERCULOSIS 3OI 

In the subacute variety the principal symptoms are fever 
and wasting. The temperature is irregular. Cough 
and dyspnea are present, expectoration is absent before 
four years of age. Hemoptysis is rare, respirations are 
accelerated, the spleen is often enlarged, anemia is marked, 
dropsy is rare, and then only late in the disease. Sweating 
is also seen late in the disease. 

The chronic cases resemble protracted bronchopneu- 
monia. Often periods of freedom from the disease are 
observed. At the first fresh cold the symptoms reappear. 
This condition of affairs may continue over. an indefinite 
period. It may terminate by becoming acute or subacute 
in form, when the symptoms observed in those conditions 
will be found. It may cause general miliary tuberculosis 
or tubercular meningitis. The presence of the tubercle 
bacillus in the sputum makes the existence of the disease 
positive. 

ACUTE MILIARY TUBERCULOSIS OR ACUTE GENERAL 

TUBERCULOSIS 

This is- an acute infectious disease excited by the tubercle 
bacilli and characterized anatomically by the simultaneous 
formation of miliary tubercles in many parts of the body. 
The disease usually develops in early life and is secondary 
to some primary lesion, as a tubercular gland. The bacilli 
are probably disseminated by the veins. All the organs 
may be uniformly infiltrated with the tubercles, but 
more commonly certain organs, like the lungs and brain, 
are more affected than the others. 

Symptoms. — There is debility, loss of flesh and strength, 
the temperature ranges between 102° F. and 103° F., and 
is characterized by an evening rise. There is cough, 



302 DISEASES OF CHILDREN FOR NURSES 

rapid respirations, and symptoms of the typhoid state 
are present. Tubercle bacilli are rarely found. If the 
lungs are chiefly affected, dyspnea, cough, and expec- 
toration will be marked. When the intestines and the 
peritoneum are mainly involved, pain, distention, abdom- 
inal tenderness and diarrhea will be the most prominent 
symptoms. 

TUBERCULOSIS OF THE BRONCHIAL LYMPH-GLANDS 

This condition is frequent in childhood. The general 
symptoms of tuberculosis are present; namely, fever and 
wasting. The other symptoms are lacking. 

The usual result of such an inflammation is a rupture 
of the gland with subsequent involvement of the lungs. 

Eustace Smithes sign is supposed to be diagnostic of 
.enlarged bronchial glands. It is demonstrated as follows: 
A stethoscope is placed over the large blood-vessels of the 
chest (at the base of the heart), with the child's head 
forward on the chest; then bend the child's head as far 
back as possible, and, if a murmur is then heard which 
was previously absent, enlarged bronchial glands exist. 
The murmur is caused by the pressure of the enlarged 
glands upon the vessels, the position of the head bringing 
them into apposition with these vessels. Bronchial 
glands that are not enlarged will not produce this sign. 

TUBERCULAR MENINGITIS 

Tubercular meningitis is fully described under diseases 
of the nervous system (see page 208) . 

TUBERCULAR DISEASE OF THE BONES AND JOINTS 
Pott*s disease is tuberculosis of the spine. It may be 
located in the cervical, dorsal, or lumbar regions of the 



TUBERCULOSIS 



303 



spinal column. It causes a necrosis or caries of the ver- 
tebrae. 

Symptoms. — The disease comes on insidiously. The 
earliest symptoms are due to irritation of the spinal nerve 
roots. Pain is the most prominent of these and is referred 
to various parts of the body supplied by the distribution 
of the nerves affected. 




Fig. 86. — Pott's disease of the upper dorsal vertebrae. Sharp-angled kyphosis. 
(Clinic of von Ranke-Herzog, Munich.) 



In a short time there is a rigidity of the spine and the 
child assumes various postures to prevent the diseased 
surfaces of the vertebrae from rubbing together. If he 
stoops to pick anything from the floor he does so without 
bending his back. Jumping from elevations hurts him 
and pulling the head av^ay from the body relieves him. 



304 DISEASES OF CHILDREN FOR NURSES 

Soon an angular deformity called kyphosis appears at 
the seat of the disease in the spine. This progressively 
becomes worse, making a permanent deformity commonly 
called hunch-hack. 

The tubercular process causes softening of the vertebrae 
and abscess formation. 

These abscesses vary in their location according to the 
seat of the lesion. In cervical Pott's disease they may 
be retropharyngeal; in dorsal and lumbar Pott's disease 
they may point in the small of the back or burrow through 
the sheath of the psoas muscle and point in the thigh at 
the lower attachment of the muscle. This is called a 
psoas abscess. In addition to these symptoms there is 
fever, wasting, pain, insomnia, and paralysis. 

Prognosis. — If the children are made to rest, given 
proper care and attention, and their backs immobilized, 
a cure will result in a large number of cases. 

Plaster jackets and other mechanisms are applied to 
keep the back rigid. Abscesses have to be opened and 
drained. 

Coxalgia or coxitis is a tubercular inflammation of 
the hip-joint. It causes necrosis of the bones of the 
joint. 

Symptoms. First Stage. — The disease begins insid- 
iously. The first symptom noted is slight lameness or 
the fact that the child wears out one shoe quicker than its 
mate. In a short time pain develops, due to muscular 
spasms. The pain is referred to the knee, often causing 
this joint to be suspected when the hip is really at fault. 
These symptoms may last a few weeks or even longer. 

Second Stage. — During this period the leg is in a char- 
acteristic position. The foot is everted, the thigh is 



TUBERCULOSIS 305 

slightly flexed and rotated outward, and the leg is appar- 
ently lengthened, due to the tilting of the pelvis. 

The joint is locked from constant muscular spasm and 
abscesses form about the hip- joint. The duration of this 
stage is indefinite. 

Third Stage. — In this stage the joint has been destroyed. 
The thigh is flexed on the abdomen, it is rotated inward, 
the foot is inverted, there is shortening of the leg, and a 




Fig. 87. — Hip-joint disease showing tilting of the pelvis in abduction, and apparent 
lengthening (left leg) (Moore). 

curvature of the spine. Ankylosis or a permanent union 
of the bones may result, which prevents any movement of 
the head of the femur. 

Treatment. — Coxalgia demands absolute rest in bed 
with an extension apparatus (see Fig. 114, page 461) 
applied to the affected leg. This draws the bone down- 
ward so that the head of the femur does not come in 

contact with the acetabulum or socket of the hip- joint; 
20 



3o6 



DISEASES OF CHILDREN FOR NURSES 



it also immobilizes the joint. Abscesses are opened and 
drained. 

Tubercular arthritis is a tubercular inflammation of a 
joint. Almost any joint in the body may be involved. 
The knee, ankle, and elbow are probably the most often 
affected. 

Symptoms. — This consists of a spindle-shaped swelling 
of the joint without any signs of inflammation. It has a 




Fig. 88. — Tubercular dactylitis of the right thumb and left middle finger of a three-year- 
old child (Hecker, Trumpp, and Abt). 

doughy feeling and a whitish appearance. It has been 
called white swelling. Later it may break down, the 
joint be destroyed, and ankylosis result. 

Treatment. — This consists of immobilization of the 
joint by plaster casts. At times curetment is necessary. 

Tubercular Osteomyelitis. — This is an inflammation 
of the shaft of the bone characterized by swelling and 
necrosis of the bone. The dead portion of the bone has 
to be removed. 



TUBERCULOSIS 30/ 

Epiphysitis is an inflammation of the ends of the bones. 
Tubercular dactylitis is an inflammation of the bones of 
the hands and feet. 

TUBERCULAR ADENITIS 

This is seen chiefly in the cervical lymph-glands, and 
is characterized by swelling, softening and breaking down 
of the glands, sinuses resulting. 

TREATMENT OF TUBERCULOSIS 

Prophylaxis. — Sputum of consumptive children should 
be received in suitable vessels which contain antiseptic 
solutions, and subsequently destroyed. Phthisic mothers 
should not nurse their offspring. The healthy should not 
sleep in the apartments of those affected. 

The treatment of tubercular* children aims to 
strengthen their vitality and resisting powers and to 
destroy or disable the tubercular bacillus. This is brought 
about by good food, fresh air, frequent bathing, sunlight, 
avoidance of exposure, graduated exercise, a dry, well- 
ventilated house and plenty of sleep and recreation. In 
bone and joint diseases absolute immobility of the part 
affected is essential. 

Hemorrhage from the lung in childhood is infrequent. 
If it should occur, the child should be kept absolutely quiet 
and an ice-bag applied to the chest. The physician should 
be immediately notified. 

Immohilizing the lung by induction of pneumothorax 
is a plan of treatment which gives good results in many 
cases of pulmonary tuberculosis. 

Sterile nitrogen is introduced into the pleural cavity 
through a thin hollow needle. A special apparatus is 



3o8 



DISEASES OE CHILDREN FOR NURSES 



used, and at intervals of a day or two measured quantities 
are injected until the lung is completely collapsed. The 
pleural cavity requires refilling every month or two. 

Nursing. — The room should be sunny, cheerful, and 
well ventilated. In tuberculosis of the lungs the child 




Fig. 89. — Proper clothing for outdoor schools and for open-air treatment, 
is holding a paper napkin in front of face while coughing. 



The child 



should live in the fresh air. If it is too cold or stormy to 
stay out of doors, the windows in the nursery should fre- 
quently be raised to keep the atmosphere thoroughly 



TUBERCULOSIS 



309 



fresh. At night the windows should be wide open, the 
child thoroughly covered, and not exposed to the draught. 



>A 



cr 




It is important that patients be convinced of the great 
benefits to be derived from outdoor treatment. Even 



310 DISEASES OF CHILDREN FOR NURSES 

dispensary patients living in the slums may sleep on 
housetops, laundry-flats, or in tents in yards. 

To meet the out-of-door sleeping problems the Klon- 
dike bed has been devised. 

Klondike Bed. — This bed is made in the regular way, 
with a sheet of asbestos over the wire spring mattress. 
Heavy brown paper may be substituted for the asbestos. 
The foundation of the bag is first, a double blanket 
folded in half, crosswise, and then a single wash blanket 
to serve as a sheet. Over this foundation a single wash 
blanket is used and over this a double red blanket. At 
the foot of the bag may be placed hot-water bottles or 
hot bricks. Over this mattress army blankets or horse 
blankets jaay be used, well tucked. Next, have a piece 
of canvas, a canvas envelope, or a rubber sheet with the 
rubber side out to keep off rain and snow. Place the 
pillows in an inverted position to keep the shoulders 
warm. 

Sleeping-out clothing may consist of bed shoes, flannel 
pajamas, and a sleeping hood with cape attached, made 
of double thicknesses of flannel having elastic sewed at 
bottom to allow the arms to go through. This makes the 
cape fit snugly over the shoulders. After arising in the 
morning the patient should always dress in a warm room. 

Cleanliness must be insisted on in tuberculosis. 
Brooms or other appliances which raise dust should not 
be used in the sick-room. Proper conditions may be 
maintained by the use of damp cloths and washing up the 
floors. It is advisable to remove all unnecessary furni- 
ture and hangings as they accumulate dust. 

It is always well in private and hospital nursing to 
keep separate dishes for the use of the patient. The 



TUBER CUL OS IS 3 1 1 

visiting nurse may instruct the family to mark and boil 
the dishes, forks, and spoons which the patient uses. 

Frequent bathing and friction of the skin are essen- 
tial. The bowels should be kept regular. Exercise 
should be taken only upon physician's permission. 




Fig. 91. — Improvised inexpensive ice-chest. It consists of a wooden box with 
lid covered with four or five layers of newspapers, all of which may be covered with 
oil-cloth. A bucket is placed in the box with sawdust under and surrounding it. The 
bottles of milk and the ice are placed in the bucket and all is covered with a lid. 

In tuberculosis of the bones and joints the part should 
be kept absolute immobile. The method of applying 
extension will be found on page 460. Any pus from 



312 DISEASES OF CHILDREN FOR NURSES 

tubercular lesions should be covered with carbolic acid, 
I to 20, and allowed to stand for half a day before dis- 
posal. 

The diet should be wholesome. Raw eggs and milk 
should be taken to build up the system. Plenty of sleep 
and exercise without exertion are beneficial. Reference 
to the caloric value of foodstuffs will be helpful. (See 
page 392). 

Disinfection of Excreta. — For this purpose chlorid of 
Hme is the best disinfectant. It should be thoroughly 
mixed with stools, urine, and sputum and allowed to 
stand in order to become saturated. If through careless- 
ness or ignorance of a patient sputum accidentally es- 
capes to the floor, lye in full strength should be used, as 
this disinfectant destroys the mucus as well as the bacilli. 
Bed-pans and urinals should always be boiled. 

Care of Soiled Bed Linen. — Bedding soiled with feces 
or urine should be washed in formahn and then boiled 
immediately. Boiling is a safe procedure for destroying 
tubercle bacilli. After drying, all bedding and clothing 
should be placed in a room and fumigated with formalin. 
The proper proportions are one quart of formalin to 
six ounces of permanganate of potash. It should be al- 
lowed to stand twenty-four hours. It is well in private 
nursing to have bed and body clothing boiled separately 
before placing with the family laundry. 

Disposal of the Sputum. — Tissue-paper napkins are 
used in preference to cups or flasks. The children should 
be carefully instructed in their use, collecting them in 
small paper bags to be burned. They have the advan- 
tages of low cost, cleanliness, and burn readily on disposal 
after use. 



TUBERCUL OSIS 3 1 3 

The sputum for examination should be collected in a 
sterile bottle with a wide mouth. In children under four 
years of age the best method to obtain sputum is as fol- 
lows : Place cotton about the end of an applicator. Grasp 
the tongue and pass the applicator close to it back to the 
pharynx; this should excite a cough, when the sputum can 
be swabbed out, or the applicators may be placed by the 
child's bedside and when the nurse notices a severe attack 
of coughing the child is picked up and, if possible, the 
sputum is obtained in the same way. Another easy method 
of obtaining sputum is to place a large (J-ounce) eye-drop- 
per in one end of a catheter. The bulb should be com- 
pressed and the catheter passed to the pharynx. The bulb 
is then allowed to expand; the suction then draws the 
sputum into the catheter. 



CHAPTER XV 

CONTAGIOUS DISEASES 

A contagious disease is one that can be transmitted 
through contact with the patient. 

SCARLET FEVER OR SCARLATINA 

This is an acute contagious disease characterized by 
high fever, rapid pulse, a scarlet rash, and an unusual 
tendency to nephritis. The germ that causes scarlet 
fever has not been discovered. The contagion is carried 
by the clothes, bed-clothing, or other articles which have 
come in contact with a patient suffering from scarlet fever. 
Milk is suspected of sometimes being a means of dis- 
semination. The disease can be transmitted by direct 
inoculation and, therefore, is characterized as a contagious 
disease. The poison is extremely tenacious to life, 
infected clothes unused for years being known to lead to 
fresh outbreaks. The young are especially predisposed, 
but not equally so. One attack practically gives immunity, 
as second attacks are uncommon. 

Period of incubation is from a few hours to a week. 

Symptoms. — Mild Cases. — At times the symptoms of 
scarlet fever are so mild that the disease may escape 
notice. 

There is fever, a slight sore throat and a very faint 
rash, often escaping proper diagnosis ; a hot bath will cause 
such a rash to show plainly. It may fade away very 
314 



CONTAGIOUS DISEASES 



315 



quickly and the character of the rash not be suspected 
until slight desquamation appears. This form is con- 
tagious and is especially dangerous, as it is often not 
isolated. 

Ordinary Case. — The disease begins suddenly with 
vomiting or it may be ushered in with convulsions. 

Throat Symptoms. — There is pain and difficulty in 
swallowing, fulness and tenderness under the jaw, and 
enlargement of the lymphatic glands. The tongue is at 







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Fig. 92. — Pulse ( ) and temperature ( ) of a simple uncomplicated scarlet 

fever. The acme in this case was reached somewhat late; the defervescence is rather 
marked (Kerr). 

first heavily coated, red at the tip and edges. This white 
coat peels off, beginning at the edges, and in a few days 
it disappears and the papillae of the tongue become bright 
red and swollen. 

This appearance has given rise to the name strawberry 
tongue. The whole posterior portion of the mouth and 
pharynx are deeply injected and may show a punctiform 
erythema before the rash appears on the skin. In severe 
cases the tonsils may be the seat of follicular inflammation 
or they may be covered with false membrane. 



3l6 DISEASES OE CHILDREN FOR NURSES 

Eruption. — A scarlet punctiform rash appears, at the 
end of the first or the beginning of the second day, on the 
neck and chest and spreads over the entire body. Some- 
times the appearance of the rash is delayed. It disappears 
on pressure and if the finger-nail be drawn through it a 
white line will remain -for a second or two. It may be a 
uniform rash or it may appear in patches with healthy 
skin surrounding it. 

In five or six days the rash gradually disappears and a 
scaly desquamation or peeling follows. 

A bright rash shows a strong heart; sudden fading of 
the rash may mean heart failure. In some cases the rash 
is slightly papular or vesicular {scarlatina miliaris). 

Febrile Symptoms. — The fever rises abruptly, reaching 
the maximum temperature of 104° F. to 105° F. in twenty- 
four or forty-eight hours, and remaining at about this 
height for three or four days and then falling by lysis. 
The duration of the febrile period is from seven to nine 
days. The pulse is rapid, out of all proportion to the 
fever, and the respirations are accelerated. The appetite 
is lost, the bowels are constipated, and the urine is scanty 
and high colored and often contains albumin. 

Nervous Symptoms. — Restlessness, headache, insomnia, 
delirium, and convulsions may occur. Convulsions occur- 
ring late in the disease are very significant of uremia. 

More Severe Cases. — Anginoid Scarlet Fever. — This 
form is characterized by severe throat symptoms. The 
tonsils are much swollen and often covered with a false 
membrane. The fever is high and the prostration is 
profound. Ulceration, and, at times, gangrene of the 
throat occur; the carotid artery may be involved. In this 
form death may result from exhaustion, aspiration pneu- 





The eruption of scarlet fever on the third day (Hecker, Trumpp, and 

Abt). 



CONTAGIOUS DISEASES 317 

monia, or hemorrhage from an ulceration of the carotid 
artery. 

Malignant Scarlet Fever. — This is a very severe form of 
the disease. The onset is abrupt, with a chill, vomiting or 
a convulsion. The fever is very high (106° F. to 107° F.). 
The pulse is rapid and feeble. Delirium sets in and is 
followed by coma. Death may result before the appear- 
ance of the rash in twenty-four or forty-eight hours. The 
rash, if present, may become hemorrhagic. 

Complications. — Nephritis. — This usually develops 
during convalescence and, as it may be unattended by 
subjective symptoms, the urine in a case of scarlet fever 
should be examined daily in order to detect immediately 
the presence of albumin. In other cases the onset of 
nephritis is recognized by the suppression of urine, the 
development of uremia, and the appearance of dropsy. 

Nephritis may be the immediate cause of death, but 
more commonly the case ends in recovery or in chronic 
nephritis. 

Among other complications may be mentioned hyper- 
pyrexia, endocarditis, pericarditis, pneumonia, suppura- 
tion of the lymphatic glands, ophthalmia, inflammation 
of the middle ear, chorea, and a peculiar inflammation 
of the joints resembling rheumatism. 

Prognosis. — Always guarded. The mortality varies 
in different epidemics from five to forty per cent. 

Treatment and Nursing. — A case of scarlet fever 
should be immediately isolated. It is kept in isolation for 
at least six weeks, for it takes that length of time for the 
peeling to be completed. Children should not mingle with 
others for a month following their release from quaran- 
tine and should not sleep with others for three months. 



3i8 DISEASES OF CHILDREN FOR NURSES 

Cases of scarlet fever should be kept absolutely at 
rest to avoid complications and should be given a liquid 
diet as long as the fever lasts. 

The rash and the peeling which follows render it 
necessary to anoint the surface of the body with cold cream 
or carbolized vaselin two or three times a day. This 
relieves the itching and irritation of the skin and controls 
the desquamation. 

To avoid the danger of nephritis the children should be 
encouraged to drink water or lemonade freely. 

The nose and throat should be sprayed with antiseptic 
solutions. Nervous symptoms are relieved with ice-caps 
and cool sponges. Cardiac weakness should be combated 
by heart stimulants. 

Isolation and Disinfection in Contagious Cases. — Pro- 
phylaxis should be complete, as the disease is highly 
contagious and is prone to leave many serious complica- 
tions. The room selected should be at the top of the 
house if practicable, and it should have plenty of ventila- 
tion and be bright and sunshiny. All upholstered furni- 
ture should be removed, curtains and hangings taken 
down, and the carpets taken up. 

Where possible, two rooms and a bath should be set 
aside for the nurse and the patient. They must be iso- 
lated from the rest of the house, and no one should be 
allowed in the room except the physician and the nurses, 
unless he gives permission. 

The nurse should not eat her meals in the room with the 
patient. 

The room should be wiped up daily with a duster moist- 
ened with carbolic, bichlorid, or a 2 per cent, formalin 
solutions. The floor should be swept with a broom 







Scarlatinal angina (third day) (Hecker, Trumpp, and Abt). 




Follicular tonsillitis (Hecker, Trumpp, and Abt) 



CONTAGIOUS DISEASES 319 

covered with a duster also moistened with the disinfecting 
solutions. After use, all dusters should be thoroughly 
soaked in disinfectant and then washed. 

The dishes and linen should be placed in separate 
metallic vessels containing water; these vessels should be 
draped in sheets wet with disinfecting solution. They 
should be removed daily. 

Unused food can be put into a similar receptacle, which 
should be removed three times a day. The contents 
should be burnt. 

Sheets wet with carbolic acid, 1 140, should be hung over 
the doorways. All desquamation should be immediately 
burned or immersed in carbolic acid. The thorough 
disinfection of all articles which come in contact with the 
child is absolutely necessary. The nurse should be 
protected by a gown and cap, and before going out should 
take an antiseptic bath (see page 470) and change all of 
her clothing. The physician should be protected by a 
gown and cap while in the room and before leaving should 
wash his face and hands in an antiseptic solution. 

The contagium is contained in the secretions such as 
the urine, bowel movements, perspiration, and discharges 
from the nose and ear. All of these should be disinfected 
by covering with carbolic acid, i : 40. The mildest cases 
should receive the same treatment and care, and isolation 
should be for the same length of time. 

The stools should be received in a vessel containing a 
disinfectant. An equal quantity of disinfectant to the size 
of the excreta should be added, the whole thoroughly 
mixed, and allowed to stand for a half-hour before emptying 
into the water-closet hopper. The bed-pan should contain 
disinfectant when not in use. It should be thoroughly 



320 DISEASES OF CHILDREN FOR NURSES 

rinsed in warm water before placing it beneath the child, 
otherwise the disinfectant might burn the buttocks. 

After recovery the child should be given a warm bath 
and shampoo with bichlorid, i : 5000, rolled in a clean sheet 
which has not been in the isolation rooms, and carried to 
another room, where he can be dressed. 

The rooms should then be sealed, all articles in the iso- 
lation rooms hung over lines, and the rooms fumigated 
with formaldehyd. 

The disinfection of the nurse is practically the same as 
for the patient. 

A discharging nose or ear may be capable of causing 
the disease after the desquamation has ceased. Cases of 
empyema following scarlatina have caused outbreaks in 
surgical wards. 

MEASLES OR RUBEOLA 

This is an acute contagious disease characterized by 
catarrh of the respiratory tract, moderate fever, and a 
papular eruption appearing on the fourth day, lasting 
two or three days, and disappearing by fine desquamation. 
The rash also has the tendency to form crescents. 

Measles is a highly contagious disease. The poison is 
transmitted through the clothing and other articles which 
have come in contact with the person suffering from the 
disease; it can also be contracted by direct contact. 

The contagium is apparently associated with the nasal 
and bronchial secretions, but has not been isolated. 

Measles is most commonly observed in children, but 
unprotected adults are very liable to be attacked. It is 
essentially an epidemic disease, but now and then sporadic 
cases are seen. One attack is fairly protective, but does 
not give absolute immunity. 






The eruption of measles two days after its first appearance (Hecker, 

Trumpp, and Abt). 



CONTAGIOUS DISEASES 



321 



The period of incubation is two weeks. 

Symptoms. — Prodromal. — There is chilliness, coryza, 
watering of the eyes, photophobia (the inability to stand 
light), cough, and drowsiness. 

The Fever. — The temperature rises rapidly to 102° F. or 
103° F., but on the second day there is decided remission, 
the temperature remaining down until the appearance of 
the rash on the fourth day when it again rises to or beyond 
the first range of temperature. It remains at this height 
for two or three days and then falls by crisis. 



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Fig. 93. — Temperature chart of rubeola of moderate severity in a child of four and 

one-half years (Kerr). 

The Catarrh. — There is redness of the conjunctiva, 
lacrimation, sneezing, hoarseness, cough, and expectora- 
tion. There may be vomiting and diarrhea. A slight 
adenitis of the cervical glands is common. 

Rash. — This appears on the fourth day on the face and 

rapidly spreads over the entire body. It is composed of 
21 



322 DISEASES OF CHILDREN FOR NURSES 

small, dark red, velvety papules which form groups having 
crescentic borders. There is an eruption on the mucous 
membrane of the throat one day before the rash appears 
on the skin. 

In two or three days the eruption begins to fade and a 
fine desquamation soon follows. 

Koplik^s Sign. — This consists in minute bluish-white 
specks surrounded by a red areola, appearing on the 
mucous membrane lining the cheeks and lips one or two 
days before the rash appears. 

Malignant or hemorrhagic measles is a form of the 
disease which occurs under bad hygienic conditions and 
is characterized by a petechial rash, hemorrhages from 
the mucous membranes, and by profound prostration. 

Complications and Sequelae. — By far the most 
prevalent are capillary bronchitis or catarrhal pneumonia 
and otitis media. Gastro-intestinal disturbances, cancrum 
oris, tuberculosis, and paralysis are also seen. 

Prognosis. — Guardedly favorable. Complications are 
apt to occur and render the prognosis grave. The usual 
mortality is low. In epidemics and in hospitals at times 
it is as high as 30 or 40 per cent. The majority of the 
deaths are due to bronchopneumonia. 

Treatment and Nursing. — Measles must be isolated. 
The quarantine is not so rigid as in scarlet fever, for six- 
teen days only is the length required. A dark room must 
be chosen on account of the photophobia, or intolerence 
to light. 

The methods for isolation and disinfection are described 
on page 318. 

The treatment is symptomatic. Inunctions of carbolized 
vaselin are used to allay the irritation and help the des- 








Koplik's spots in measles (Hacker, Trumpp, and Abt), 




Appearance of the throat in measles (Hecker, Trumpp, and Abt). 



CONTAGIOUS DISEASES 



323 



quamation. Warm baths are given after the rash dis- 
appears to facilitate desquamation. 

The most important complications to guard against in 
measles are bronchopneumonia and otitis media. To 
avoid these children should remain in bed and a flannel 
or cotton jacket should be worn. The chest should be 
rubbed daily with some counterirritant, such as camphor- 
ated oil or amber oil. Earache should be treated by syr- 
inging the ear with hot water (see pages 443 and 444). 

It is advisable for the child to wear some form of pro- 
tection over the ears throughout the attack. A simple 
expedient is to place cotton in the external auditory meatus 
and cover the head and ears with a snugly fitting cap. 

The nose and throat must be frequently cleansed with 
antiseptics or normal salt solution. 

ROTHELN OR RUBELLA 

This is an acute contagious disease resembling both 
scarlet fever and measles, but differing from both in its 
short course, slight fever, and freedom from sequelae. 
The disease is highly contagious ; the poison may be 
carried in the clothes or may be directly transmitted. 

Symptoms. — Prodromal symptoms are slight or absent. 
The disease begins with drowsiness, slight fever, and sore 
throat. The eruption appears on the first or second day 
and varies greatly in character. In some cases the rash 
is composed of small, red, slightly elevated papules resem- 
bling measles; in others the rash is bright red and diffuse, 
resembling scarlet fever. It begins on the face and spreads 
rapidly over the entire body, but it fades so quickly that 
the face may be clear before the extremities become 
involved. Slight desquamation frequently follows, though 



324 DISEASES OF CHILDREN FOR NURSES 

it is often absent. Apart from the sore throat the catarrhal 
symptoms are slight. The superficial cervical and pos- 
terior auricular lymph-glands are more swollen than in 
measles. The duration is from three to five days. 

The prognosis is good. Isolation for five or six days 
is advisable, though not imperative. 

Nursing. — The disease does not require much attention. 
The room should be darkened, the nose and throat v^ashed 
with antiseptic sprays, and the temperature, pulse, and 
respiration taken twice a day. 

DIPHTHERIA 

This is an acute contagious disease excited by the 
Klebs-Loffler bacillus and characterized by moderate 
fever, great prostration, glandular enlargement, and a 
fibrinous exudate which is usually located in the throat. 

Etiology. — ^Diphtheria is most common between the 
ages of three and six in children who suffer from catarrhal 
conditions of the nose and throat. The poison is contained 
in the secretions of the throat and may be transmitted 
through the atmosphere and through the clothing. One 
attack does not protect the child from a second. The 
Klebs-Loffler bacillus is found in the membranous exudate 
and the constitutional symptoms result from the poison 
generated by this bacillus. 

The membrane is not a true membrane, but a necrosis 
of the superficial cells of the mucous membrane caused 
by the Klebs-Lofiier bacillus. It is grayish-white in 
appearance and more or less adherent, so that when it is 
stripped off it leaves a raw, bleeding surface. Sometimes 
the necrosis extends to the deeper tissues, causing wide- 
spread ulceration and gangrene. The membrane is 



CONTAGIOUS DISEASES 325 

usually found on the tonsils, pillars, and pharynx, but it 
may extend to the mouth, larnyx, and nose. It is then 
called laryngeal diphtheria or membranous croup, and 
nasal diphtheria, respectively. The lymphatic glands are 
considerably swollen; the spleen is engorged. The lungs 
frequently show bronchopneumonia. 

Types. — According to location, there may be jaucial, 
laryngeal, nasal, and cutaneous diphtheria. According to 
the severity of the attack the disease may be mild, grave, 
and malignant. 

The period of incubation is from two to ten days. A 
condition, resembling faucial diphtheria, called Vincent's 
angina has already been described on page 123. 

S)niiptoms. — Catarrhal diphtheria, so-called because 
there is an absence of membrane, is only a catarrhal con- 
dition of the nose and throat; the secretions, however, 
contain the Klebs-Loffler bacillus. The symptoms are 
mild, but the risk of spreading the contagion is great. 

Faucial Diphtheria of Ordinary Severity. — The disease 
commonly begins with a chill, moderate fever, malaise, 
and sore throat. The fever, as a rule, is not very high, 
102° F. to 104° F., and its course is quite irregular. The 
pulse soon becomes rapid and feeble, the bowels are con- 
stipated, the urine is scanty and frequently albuminous, 
and the prostration is out of proportion to the severity of 
the febrile symptoms. 

Local Phenomena of Faucial Diphtheria. — The child 
complains of difficulty in swallowing, the muscles of the 
neck feel stiff, and there is tenderness under the jaw. 
The lymphatic glands are considerably enlarged and the 
tonsils are covered with grayish-white membrane which, 
when stripped off, leaves a raw, bleeding surface. The 



326 DISEASES OE CHILD Ji EN FOR NURSES 

membrane soon forms again and may extend to the 
larynx and into the nose. The average duration of the 
disease is from one to two weeks. 

Laryngeal Diphtheria. — This is usually secondary, by 
extension from the faucial diphtheria, but it may be 
primary. It is recognized by hoarseness, aphonia (loss 
of voice), croupy cough, progressive dyspnea, and stridu- 
lant breathing. The wings of the nose play, the stemo- 
mastoid muscles are prominent, and other signs of dyspnea 
are present. Shreds of false membrane are sometimes 
expectorated during violent fits of coughing. The febrile 
symptoms are usually slight. Death often results from 
suffocation, but recovery is not impossible in the most 
unpromising cases. Intubation is necessary at times 
(see page 332). 

Nasal Diphtheria. — This is nearly always secondary. 
It is recognized by an offensive discharge from the nose, 
epistaxis, and excoriation of the lips and wings of the 
nose. The false membrane may be detected within the 
nasal chambers upon inspection. 

Cutaneous Diphtheria. — This may be primary or secon- 
dary. The constitutional symptoms are similar to those 
of faucial diphtheria. The membrane may appear at any 
point where there is excoriation. 

Complications. — Capillary bronchitis, pneumonia, 
myocarditis, otitis media, nephritis, and paralysis. The 
most prevalent are bronchopneumonia, nephritis, and 
postdiphtheritic paralysis, the latter generally occurring 
during convalescence and being observed in about 15 per 
cent, of all cases. 

Post-diphtheritic Paralysis. — ^There is no relation be- 
tween the severit;^ of the attack of diphtheria and the 




Diphtheria of the hps (Hecker, Trumpp, and Abt). 




Pharyngeal diphtheria (Hecker, Trumpp, and Abt). 



CONTAGIOUS DISEASES 32/ 

liability to paralysis. Mild cases which are thought to be 
simple pharyngitis at times are followed by troublesome 
paralysis. The pharynx is usually the principal seat 
of the paralysis, which can be recognized by difficult 
swallowing and imperfect speech, and frequently the 
regurgitation through the nose of liquids. Next in fre- 
quency the eyes are involved and there is strabismus 
(cross-eyes), and ptosis (dropping of the, upper lids). 
The heart may be affected and in such cases, if death does 
not immediately result, there may be a remarkable slowing 
of the pulse. In some cases there is an extensive involve- 
ment of the extremities. Recovery from the paralysis 
usually occurs. 

Prognosis. — Always guarded. The mortality of diph- 
theria is from 10 to 50 per cent. In true faucial diphtheria 
the prognosis is usually good. In laryngeal and nasal 
it is grave. Three-fourths of the cases which end fatally 
die of exhaustion. 

Treatment. — Prophylaxis. — In no other disease are 
prophylactic measures so imperative as in diphtheria. 
All cases of recognized diphtheria, as well as all cases of 
suspected diphtheria, should be immediately isolated. 
Other children in the family should not be allowed to 
attend school. The suspected cases of diphtheria should 
be kept in isolation until two or three negative cultures are 
obtained. If diphtheria is not present this means only 
two or three days' isolation. 

In true cases of diphtheria the quarantine should be 
kept up until a negative culture is obtained, after the 
throat symptoms are well. This is usually in from ten 
days to two weeks. 

At times it is necesssary for the nurse to obtain the 



328 DISEASES OF CHILDREN FOR NURSES 

culture from a case of diphtheria. To do this she must 
follow the instructions as given on page 47. 

Special attention should be paid to all attacks of croup 
in children, especially to those attacks which do not come 
on suddenly in the night. It may be laryngeal diphtheria. 

Do not examine an infant's throat immediately after 
feeding. 

Antitoxin is obtained from selected horses. The method 
by which it is produced is as follows: The horse is 
given a mild case of diphtheria by injecting a few Klebs- 
Loffler bacilli into its system. The horse recovers from 
the attack. A second attack is induced by the same 
methods. It takes a larger number of bacilli to cause a 
reaction than it did at first, showing that a certain resist- 
ance to the poison has developed in the blood of the horse. 
Other injections are made, each more powerful than the 
preceding, and are continued until the horse fails to 
develop any symptoms of diphtheria, even though doses are 
used which would have killed him at first. This proves 
that the blood contains sufficient resistance to the poison 
or the toxin of diphtheria to destroy the bacilli as soon as 
they enter the system. The blood is then withdrawn, 
and the serum alone is used. It is standardized and 
called antitoxin, because it contains the principle which 
overcomes the toxin of diphtheria. 

The only annoying symptom attending its administra- 
tion is the appearance of hives. 

The reason for giving antitoxin is to throw into the 
human system at once a large amount of resistance to the 
growth and development of the Klebs-Loffler bacilli. 
The same resistance or antitoxin is manufactured in the 
human system, but it takes days for it to become of suffi- 



CONTAGIOUS DISEASES 



329 



cient strength to combat the bacilli which are developing 
with almost equal rapidity. The immense advantage of 
throwing fully developed antitoxin into the system to 
combat the early and unorganized attack of the bacilli is 




Fig. 94. — Position for intubation. The child's legs are wrapped in a blanket, and 
grasped between knees of nurse. Her arms are passed beneath child's and her hands 
fix the head. 

evident. It is like having a standing army to quell in- 
cipient revolts. 

To obtain the best results large quantities of antitoxin 
should be used early in the disease; even before the 
diagnosis is made in suspicious cases. If no improvement 



330 



DISEASES OF CHILDREN -FOR NURSES 



is noticed within twelve hours the dose is repeated. The 
dose of antitoxin for children is from 2000 to 4000 units. 
It is given hypodermically. It is influenced by the weight 
of the child; heavier children require larger doses. 

Nursing. — The room should be selected as in scarlet 
fever, and the methods for isolating and nursing contagious 




Fig. 95- — Position for intubation. The child's head is allowed to fall backward and is 
firmly held in position behind edge of table. 

cases as described on page 318 should be followed. A 
moist atmosphere should be maintained. 

All cases which have been exposed to the contagium 
should be immunized with about 1000 units of antitoxin; 
this immunity will last for about one month. 

The nurse in charge of the case should also receive an 



CONTAGIOUS DISEASES 



331 



immunizing dose of antitoxin. As the contagion is not 
contracted through the atmosphere of the room or through 
the air we breath, but through the discharges from the 
patient's nasopharynx, care should be taken in this direc- 
tion. The hands should be thoroughly washed and 
immersed in carbolic-acid solution, and all instruments 
which are used in connection with the patient should be 




Fig. 96. — Position for tracheotomy. The rolled blanket beneath shoulders and neck 

makes trachea prominent. 

immersed in the same solution. For this purpose a basin 
of carbolic solution, i : 40, should be kept constantly in the 
room. All linen and gauze which has been contaminated 
by the discharges of the patient should be immediately 
sterilized or burned. No one but the physician should be 
allowed in the room and he should be protected by cap 
and gown. The nurse should not leave the sick-room 
without changing her garments and washing thoroughly 
in carbolic or bichlorid solution. The nurse should 



332 DISEASES OF CHILDREN FOR NURSES 

spray her nose and throat three or four times a day with 
some antiseptic solution, and when out should not visit 
any houses, particularly where there are children. After 
a patient is well, all articles should be thoroughly fumi- 
gated and the patient should receive two disinfectant baths. 

Irrigation of nose with normal salt solution from a foun- 
tain syringe is often used in cases of nasal diphtheria. 

In faucial diphtheria the spraying of the throat with 
antiseptic or normal salt solution must be thoroughly 
done. In cases where the children are prone to eject 
pieces of membrane during irrigation, it is well for the 
nurse to protect her eyes with glasses and tie a piece of 
gauze over her mouth and nose. She should thoroughly 
disinfect her person, the bed, or the floor if" they become 
contaminated with discharges. 

The pulse should be under observation at frequent 
intervals throughout the attack and during convalescence. 

Intubation. — In laryngeal diphtheria it is necessary at 
times to perform intubation. The operation consists in 
the introduction of a tube into the larynx. It opens the 
larynx and allows free breathing in cases where the larynx 
has become almost closed from the diphtheritic membrane. 

Different caliber tubes are used for the various ages. 
During the operation it is necessary for the nurse to hold 
the child's head in the following manner: The child is 
wrapped in a blanket to secure the arms and legs. The 
nurse's legs being crossed, her knees should firmly grasp 
the child's legs, her arms should hold the child's upper 
extremities, and her hands fix the head. At times the 
child is placed on a table, the head extending over the 
end and firmly held by a nurse. The child should be 
wrapped in a blanket.. 



CONTAGTOUS DISEASES 333 

Tracheotomy. — An incision of the trachea. It is neces- 
sary at times to open the trachea below the larynx to save 
the child from suffocation. A tube is introduced through 
the opening and the breath is drawn into the lungs through 
this passage. 



Fig. g7. — Position for feeding in intubation. The head is allowed to drop over side of 
lap. Junket or semifluid food is most easily swallowed. 

Nursing. — Intubation and tracheotomy demand con- 
stant nursing and watching. In tracheotomy if a piece of 
membrane or mucus plugs up the openings in the tubes 
suffocation results. If it becomes necessary to remove 
the inner tracheotomy tube, it is unlocked and drawn out; 
it should be cleansed in boric acid. Long feathers are 
passed through the opening and the mucus dislodged. 



334 DISEASES OF CHILDREN FOR NURSES 

After the air-passages are free the inner tube is reinserted. 
A moist atmosphere should be maintained. After the 
attack is over the tube is removed, the opening closed, and 
the child resumes breathing through the naturaJ passages. 

In intubation, after the physician has introduced the 
tube, he may cut the silk thread immediately or he may 
loop it over the ear. If he does the latter, it must be held 
fast by a strip of adhesive plaster. It is also wise to tie 
the children's arms in such a way that they cannot reach 
the string and pull out the tube; cuffs may answer this 
purpose (see page 467). 

When the silk thread is to be removed, always cut the 
knot off first. If this is not done, the wrong end may be 
pulled and the knot will then catch in the hole through 
which the thread passes, causing the tube to be dislodged. 

Feeding in Intubation. — The child should be placed on its 
back across the nurse's lap and the head allowed to drop 
slightly lower than the body. This allows the food to 
pass into the pharynx and not into the larynx. Semi- 
liquids, such as gruels, junket, thickened broths, etc., are 
more easily swallowed by older children than liquid food. 

SMALLPOX OR VARIOLA 

This is an acute contagious disease characterized by 
an eruption which is at first papular, then vesicular, and 
finally pustular. 

Etiology. — The poison of smallpox is extremely 
tenacious to life, remaining alive in clothes for a long 
time, and another attack of the disease may start from 
this source. Unless protected by vaccination or a previous 
attack the whole race is susceptible, from the child in 
utero to the very aged. The negro race is especially prone 
to the disease. 



CONTAGIOUS DISEASES 335 

Symptoms. — The disease usually begins with a chill 
followed by vomiting and intense lumbar pains. The 
fever rises rapidly, reaching 104° to 105° F. in twenty-four 
hours. It continues at this height until about the end of 
the third or fourth day, when it drops several degrees. 
It remains at this new level until the vesicles become 
pustules, when a hectic fever develops which may be 
higher than the original temperature, and like all hectic 
temperatures it is marked by wide fluctuations. The 
temperature finally falls by lysis about the eighteenth day 
of the disease. All the symptoms which attend fever 
are present. 

The eruption is first noticed about the third or fourth 
day, appearing as small red spots on the face, forehead, 
and wrists. These small red spots are rapidly converted 
into small round papules which feel like shot under the 
skin. This eruption rapidly spreads over the entire 
body. About the third day of the eruption the papules 
are converted into clear vesicles, divided by small filaments 
into several parts, something like the divisions ol an 
orange. This is termed loculation. When they are 
pricked with a needle the entire contents is not dis- 
charged, but only the fluid in the divisions opened is 
obtained. The vesicles have a small impression at their 
summit which is termed umhilication, and are surrounded 
by a red ring of inflammation. 

In two or three days the fluid in the vesicles becomes 
turbid and they become pustules. The loculation and 
the umhilication disappear. Betv/een the lesions the skin 
is swollen and edematous, so that the features are unrecog- 
nizable. In three days more the pustules rupture, soft 
yellow crusts form which have an offensive odor, and 



336 DISEASES OF CHILDREN FOR NURSES 

adhere to the skin for a week or more. When the crusts 
fall off, pockmarks (small scars) remain as a permanent 
deformity. 

Confluent smallpox is a severe form of variola in which 
the pustules coalesce and the symptoms are severe. 

Malignant smallpox is associated with hemorrhages; 
at times there is bleeding into the pustules, constituting 
what is sometimes called hlack smallpox. 

Varioloid is a modified smallpox occurring in one who 
has been previously protected by vaccination. 

Prophylaxis. — Universal vaccination. 

Treatment. — The child should be immediately isolated. 
The room should be selected and the same precautions 
practised as described under Scarlet Fever (see page 3 18). 
The treatment is symptomatic. 

Nursing. — The instructions for isolating and disinfect- 
ing in contagious cases as described on page 318 must be 
followed. 

The temperature of the room should be maintained 
at 68° F. It should be darkened to prevent pitting as 
much as possible. The diet should be liquid, and plenty 
of water or lemonade given at frequent intervals. 

It is absolutely necessary that the nurse should have 
been successfully vaccinated before attending a case of 
smallpox. If she has been exposed to the disease while 
unprotected by vaccination she should be immediately 
inoculated. All others who have come in contact with 
the disease should likewise be immediately vaccinated. 
She should not go out without taking a full bichlo- 
rid bath, and then should not visit other families. 
The child's urine should be examined frequently and 
the temperature, pulse, and respiration taken every three 
hours. 





The eruption of varicella on the fourth day (Hecker, Trumpp, and 

Abt). 



CONTAGIOUS DISEASES 



337 



Itching may be relieved by frequent sponging and soak- 
ing the crusts with oil. The child's hands should be cov- 
ered with mittens, preferably wet with normal salt solution. 
The children should not be permitted to scratch themselves ; 
cuffs may be necessary (see page 467). The eyes should 
be frequently syringed, and the nose and throat sprayed. 

To prevent marked pitting: (i) The vesicles should be 
broken up with a fine sterile needle. (2) The base of 
the vesicles, after they are broken, should be cauterized 
with a sharp stick of silver nitrate. (3) The papules 
should pe painted with iodin. (4) Light and air should 
be excluded by covering the exposed skin surface with 
sweet oil and dusting upon this a powder composed of 
equal parts of bismuth subnitrate and prepared chalk 
twice daily. This forms a mask. 

VARICELLA OR CHICKEN-POX 

An acute contagious disease of short duration character- 
ized by slight fever and a vesicular eruption which dis- 
appears in two or three days. 

Symptoms. — There is slight fever and before the end 
of the first twenty-four hours there is an eruption usually 
appearing on the face and chest. At first the eruption 
consists of widely scattered papules which soon become 
vesicles. The vesicles are superficial. They are neither 
umbilicated nor loculated and usually are not surrounded 
by a red inflammatory ring. At times a small red areola 
occurs. The eruption appears in crops lasting over two 
or three days and rarely pustulates or leaves scars. The 
vesicles dry up and form crusts which adhere for a few 
days. Sometimes the drying starts at the center and thus 

gives the appearance of umbilication. 

22 



ST)S DISEASES OF CHILDREN FOR NURSES 

Erysipelas occasionally complicates the disease. 

Treatment. — The disease is contagious, but it rarely 
requires isolation. As long as the crusts are present the 
disease can be transmitted. 

Nursing. — For the itching, mild solutions of carbolic 
acids can be applied. To remove the crusts nothing is 
better than applications of ichthyol ointment. 

Mittens should be placed on the child's hands to prevent 
them from scratching themselves. 

VACCINIA (COWPOX) 

Cowpox is a general disease with a local manifestation 
acquired by vaccination. 

VACCINATION 

The value of vaccination was first shown by Edward 
Jenner, in 1798. He noticed that the dairymen who 
came in contact with the disease in cattle were rarely 
affected by smallpox. At that time smallpox was univer- 
sal, the person who was not pock-marked being the 
exception, for terrible epidemics depopulated towns and 
villages. Jenner reasoned that cowpox had rendered 
these men immune to smallpox; therefore, arbitrary 
inoculation of individuals with the scabs from affected 
cows would produce the same immunity in others. He 
was fortunate in establishing his claims and soon vaccina- 
tion became a fixed custom. 

To realize the immense benefit it has been to the human 
race it is only necessary to compare existing conditions with 
those of a hundred years ago. Now the pock-marked 
individual is the exception and epidemics are controlled. 
Antivaccination societies reason ignorantly, confuse 



CONTAGIOUS DISEASES 339 

syphilis, sometimes called pox, with vaccination, exhibiting 
pictures of syphilitic ulcers as the dire results of vaccination, 
and harp on the few instances of deaths following vaccina- 
tion which have been reported. A few bad results have 
occurred from improper technic and impure serum. This 
is not the fault of the method, it is due to the carelessness 
of the physician who vaccinates or of the manufacturers 




Fig. 98. — Normal vaccination pustule on the sixth day after vaccination (Friihwald 

and Westcott). 

in making the serum. The risk at present is practically 
nil with modem methods of asepsis. In Prussia, where 
compulsory vaccination has existed since 1874, the death 
rate per 100,000 of population has dropped from 24.45 
per cent., the average previous to 1874, to 1.51 per cent. 

A child, if healthy, should be vaccinated during the 
first two months of life, as the symptoms are very slight 



340 DISEASES OF CHILDREN FOR NURSES 

at that time. If delicate, wait until the child is in good 
condition and gaining in weight. A successful vaccination 
gives immunity for five years. Should the vaccination be 
unsuccessful, it should be repeated until a result is obtained. 

Method. — The skin surface is washed clean and 
rubbed with alcohol. Do not use antiseptic solutions, as 
they kill the germ before it enters the system and a nega- 
tive result follows. The upper layers of the skin are 
scraped o£f with a sharp bistoury until an exudation of serum 
takes place. Bleeding is to be avoided if possible. The 
serum is then introduced into the wound from the sterile 
tubes and thoroughly rubbed in by some flat instrument. 
The wound should be allowed to dry thoroughly before 
applying an aseptic dressing. This dressing should be 
renewed as long as there is an open wound and during 
the course of the local inflammation. It is as necessary 
to keep dirt and clothing out of this wound as any other. 
Severe ulcerations result from infection. 

The course of the local manifestation is similar to that 
taken by the eruption of smallpox. First a papule, then 
a vesicle, umbilicated and loculated, followed by a pustule 
and a scab. It requires about the same time for develop- 
ment as the typical rash of variola. Three days is about 
the average for each stage. 

ERYSIPELAS 

An acute contagious disease excited by the streptococci 
and characterized by a peculiar inflammation of the skin 
and subcutaneous tissues. The germs can be carried 
in the clothes. Certain children are more predisposed 
than others. Those suffering from wounds or from 
diseases which lower the vitality are especially susceptible. 



CONTAGIOUS DISEASES 



341 



The poison usually gains access through some wound or 
abrasion. In the newborn erysipelas starting at the navel 
is sometimes seen. 

Symptoms. — The disease is ushered in with a chill 
and there is fever, 104° F., with all its symptoms. The 
inflammation usually begins in the neighborhood of the 
nose and spreads upward and laterally over the head to 
the neck, where it frequently stops. The affected part has 
a crimson hue, is swollen and tense, and is limited by a 
very sharp line or a well-defined ridge, beyond which, 
however, projections can be felt creeping out into the 
adjacent subcutaneous tissue. The surface of the inflamed 
area is first smooth and glazed, but later it is covered with 
minute vesicles and blebs. The child complains of 
burning and tingling and the surrounding skin may be so 
edematous that the features are almost unrecognizable. 
In four or five days the redness begins to fade and the 
swelling disappears; desquamation follows and the fever 
falls by crisis. 

The average duration is from a week to ten days. 
Relapses are extremely common. 

Nursing.— The dressings should be kept fresh, changing 
them at least twice a day. The patient should be kept 
quiet and the urine should be examined. The clothing 
and articles which come in contact with the patient must 
be disinfected. Never put a case of erysipelas in a 
surgical ward. 

PERTUSSIS OR WHOOPING-COUGH 

A contagious disease characterized by catarrh of the 
respiratory tract and peculiar paroxysms of cough, ending 
in a prolonged, whooping inspiration. The disease is 



342 DISEASES OE CHILDREN FOR NURSES 

highly contagious, proximity to the child with whooping- 
cough being sufficient to contract the disease. One 
attack protects from others. 

Symptoms. — There are three stages, the catarrhal 
stage, the paroxysmal stage, and the stage of decline. Half 
of the cases appear in the first two years of life. 

Catarrhal Stage, — The disease begins with the symptoms 
of coryza and bronchial catarrh. It is similar to other 
cases of bronchitis, but does not respond to the ordinary 
remedies for catarrh. After two or three weeks it passes 
into the paroxysmal stage. 

In the paroxysmal stage the cough becomes more violent 
and is paroxysmal. During a paroxysm the face becomes 
cyanosed, the eyes are injected, and the veins distended. 
The cough frequently induces vomiting and in severe 
cases hemorrhages. The close of the paroxysm is marked 
by a long-drawn whooping inspiration due to the spasmodic 
closure of the glottis. The number of paroxysms varies; 
there may be from ten to twelve or, in severe forms, from 
forty to fifty in twenty-four hours. Ulcers frequently 
form on the frenum (the small attachment of the tongue 
to the floor of the mouth) from forcible propulsion of the 
tongue against the lower teeth during a paroxysm. This 
stage lasts about three or four weeks. 

Stage of Decline. — The paroxysms gradually grow less 
frequent and less violent and fmally cease. 

Complications. — Pertussis is very prone to be followed 
by some complication. Bronchopneumonia probably 
ranks as the most frequent and fatal complication, causing 
two thirds of the deaths. Convulsions occur in some 
cases. 

Prognosis. — During the first year the mortality is 



CONTAGIOUS DISEASES 



343 



about twenty -five per cent. From this time on it rapidly 
decreases. 

Treatment. — Children suffering from pertussis should 
be isolated so far as possible. They should be kept from 
school and any other children in the family sent away. 
Delicate children should be particularly protected against 
the disease. The isolated period should be continued as 
long as the spasmodic stage lasts. 

Inhalations of menthol, amyl nitrite, or a few whiffs 
of chloroform will frequently control a violent paroxysm. 

Nursing. — The child should have plenty of fresh air. 
During the day it is of benefit to take it out of doors. 
This is permissible if its temperature is not over ioo° F. 
At night the windows should be opened. Frequent 
changes of atmosphere and clothing seem to have a 
beneficial effect upon the spasms of cough. The seashore 
seems to aid in the cure of the disease. 

If a child vomits a meal a short time after eating it, 
another meal should be given. It is best to make the 
diet as liquid as possible. Infants should receive their 
milk diluted more than usual, and in severe cases it should 
be peptonized (see page 367). 

Light flannel underwear should be worn. The chest 
should be anointed with camphor oil daily, and inhalations 
of medicated steam should be employed. 

A practical measure which may be adopted in those 
cases in which vomiting occurs frequently during the 
paroxysm is to place a binder around the abdomen. 
This should be drawn tight, as it is the support which it 
gives to the abdominal muscles which is desired. By 
preventing these large muscles from being brought into 
full play during the paroxysm vomiting is frequently 



344 DISEASES OF CHILDREN FOR NURSES 

avoided, as it is usually due to their violent contraction 
making pressure on the filled stomach. 

Before disposing of the sputum and vomited material 
it should be disinfected. 

PAROTITIS OR MUMPS 
This is an acute contagious disease characterized by 
inflammation of the parotid and other salivary glands. 




Fig. gg. — Epidemic parotitis. Second day. The picture shows the uniform swell- 
ing in the region of the left ear, which has spread to the face and the submaxillary areas; 
also the characteristic elevation of the auricular lobule. The filling of the fossa between 
the mastoid process and the ramus of the lower jaw is. imfortimately, not visible (Hecker, 
Trumpp, and Abt). 

The bacilli of the disease are probably contained in the 
sputa. One attack confers immunity. 

Symptoms. — The disease is ushered in with chilliness, 
moderate fever, malaise, and a swelling of one of the 



CONTAGIOUS DISEASES 345 

parotid glands. The swelling is seen below and in front 
of the ear; the surrounding tissues are edematous and the 
submaxillary glands are soon involved. The features 
are swollen and distorted, the movements of the jaw 
are restricted and painful, and there is a decrease in the 
flow of saliva, making the mouth dry and uncomfortable. 
The other parotid is usually soon affected. The swelling 
lasts five or six days. 

Complications are not often seen. Abscess of the 
parotid gland and deafness have been reported. Some- 
times the testes in the male and, more rarely, the breasts 
or ovaries in the female are involved, but these complica- 
tions are not common in childhood. 

Treatment. — This consists of the applications of 
ichthyol ointment. The sputum should be disinfected. 

INFLUENZA OR LA GRIPPE 

An acute contagious disease characterized by fever, 
extreme prostration, pain in the head and back, and 
generally by catarrh of the respiratory or gastro-intestinal 
tract. 

Etiology. — ^The disease occurs in epidemics. The 
exciting cause is a small bacillus found in the sputum. 
When prevalent no age or sex is exempt. One attack 
does not confer immunity from others. 

Influenza does not kill except by its complications. 
The most frequent are catarrhal pneumonia, croupous 
pnuemonia, anemia, and otitis media. Tuberculosis 
of the lungs, nephritis, neuritis, and meningitis are also 
seen. 

Symptoms. — ^The disease begins with languor, chilli- 
ness, severe pain in the head and neck, and fever ranging 



346 DISEASES OF CHILDREN FOR NURSES 

from 101° to 1030 F. There is extreme prostration. 
In some cases the principal symptoms are those of the 
respiratory tract, in others the gastro-intestinal symptoms 
are most important, and in the third variety the nervous 
symptoms are most prominent. In simple cases the 
temperature falls in two or three days by crisis, but com- 
plications not infrequently prolong the case for two or 
three weeks. 

Respiratory Symptoms. — There may be coryza, laryn- 
gitis, or bronchitis. This gives rise to a nasal discharge, 
cough, expectoration, sneezing, and watering of the eyes. 
Tonsillitis and otitis media are often associated conditions. 

Gastro-intestinal Symptoms. — There is vomiting and 
diarrhea with their attending symptoms. 

Nervous Symptoms. — Neuralgic pains in the head, 
back, and limbs. In some children the nervous symptoms 
appear alone in conjunction with the fever. 

One set of symptoms only may be present, but more 
often two or more tracts are involved. Skin eruptions 
occur at times. 

Prognosis. — Uncomplicated cases nearly always recover 
in from five to seven days. 

Treatment and Nursing. — ^The disease is communi- 
cable. The child should be put to bed and kept there 
until the fever is normal. A liquid diet should be given. 
The temperature, pulse, and respiration should be taken 
three times a day. If there is catarrh, the nose and 
throat should be systematically sprayed. Earache should 
be treated by syringing the ear with water at a temperature 
of 110° F. The sputum should be disinfected. 



CHAPTER XVI 

CONSTITUTIONAL AND NUTRITIONAL 

DISEASES 

Constitutional Diseases 
rheumatism 

Rheumatism, as a whole, has varied manifestations in 
childhood. It may be articular, muscular, and neural. 
Rheumatic affections of the serous membranes, of the 
mucous membranes, and of the skin are found. The 
disease is uncommon under five years of age. 

The two most prominent types of rheumatism are 
articular rheumatism and muscular rheumatism. 

Acute articular rheumatism or inflammatory rheu- 
matism is an acute general disease characterized by 
irregular fever, inflammation of joints, and a marked 
tendency to affect the heart. In children the acute course 
with marked inflammation of the joints is uncommon. 

The cause of the disease is unknown. Some writers 
attribute acute articular rheumatism to bacterial infection, 
the germ being undiscovered. Poor hygienic surroundings, 
damp houses, and a sudden chilling of the body are the 
factors concerned in the onset of the disease. 

Symptoms. — In children under ten years of age the 
disease begins slowly. There is fever (ioo° to ioi° F.) 
and stiffness in several joints. Marked inflammation 
with swelling and pain of the joints involved is imcommon. 

347 



348 DISEASES OF CHILDREN FOR NURSES 

The ankles, knees, wrists, elbows, and small joints of the 
feet are the ones most often affected. The stiffness may 
move from joint to joint or one alone may be involved. 
At times the joints are so stiff that they make the child 
lame; more often these pains are designated as ''grow- 
ing pains." Sweats are uncommon. The muscles are 
painful and there may be rigidity in more severe cases. 
The duration is from a few days to several weeks. One 
attack seems to predispose to others and anemia may 
result. 

After ten years of age the symptoms closely resemble 
rheumatism in the adult. 

Complications. — Endocarditis is the most common 
complication and may occur in very mild cases. About 
40 per cent, of all cases of rheumatism have this com- 
plication. Pleurisy, pericarditis, pneumonia, chorea, iritis, 
meningitis, and certain cutaneous phenomena, such as pur- 
pura and urticaria, are also seen. 

Pharyngitis, tonsillitis, laryngitis, and bronchitis are 
sometimes caused by rheumatism. 

Muscular rheumatism is an affection of the voluntary 
muscles characterized by pain, tenderness, and rigidity. 

Types. — Different names have been applied, according 
to the location. 

Torticollis or wry-neck, when it involves the sterno- 
mastoid muscle. 

Lumbago when it involves the lumbar muscles. 

Pleurodynia when it involves the intercostals. 

Cephalodynia when it involves the occipitofrontalis. 

Exposure to the cold and wet, combined with muscular 
strain, usually excites it. 

Symptoms. — Pain is the chief symptom, aggravated by 



CONSTITUTIONAL AND NUTRITIONAL DISEASES 349 

the use of the muscles, and is associated with tenderness. 
Sometimes the muscles are rigid and contracted, such a 
condition being frequently seen in torticollis. 

Torticollis. — The head is fixed and inclined to one side, 
every effort to turn it being accompanied with severe pain. 
The recovery is spontaneous in a few days. 

Treatment. — Ironing the neck gives great relief. A 
small iron, not too hot, is the best implement to use. A 
piece of flannel should be laid upon the skin for protection. 

Lumbago. — There is a dull, aching pain across the 
loins which is aggravated by turning the body or attempting 
to rise from a sitting posture. 

Pleurodynia. — The pain is felt in the side and is 
increased by deep breathing, coughing, or twisting of the 
body. The respirations are restricted on the affected side 
and there is tenderness to the touch. The absence of 
fever will serve to distinguish it from pleurisy. 

Cephalodynia is characterized by superficial head 
pains which are increased by movements of the scalp and 
are associated with tenderness on pressure. 

Rheumatism frequently appears to be the cause of 
neuritis. 

Treatment. — The salicylates and the alkalies are the 
remedies used in rheumatism. 

Nursing. — The room should be kept warm and at an 
even temperature. On account of the danger of endo- 
carditis the child should be kept in bed as long as there 
is fever. "Growing pains" should never be allowed to 
explain stiffness and discomfort in children. Involve- 
ment of the heart may follow such trivial symptoms, 
rheumatism not being suspected until a heart lesion is 
found. 



3 so DISEASES OF CHILDREN FOR NURSES 

The child should be placed between blankets while in 
bed. 

If applications to the joints are necessary, it must be 
done in a way to avoid pain. 

DIABETES MELLITUS 

This disease is characterized by the presence of sugar 
in the urine, polyuria, and loss of flesh and strength. 
The exact cause of diabetes is not known. It is uncom- 
mon LQ childhood, but when it exists the course is very 
rapid. 

Symptoms. — Urinary. — The uriae is increased m 
quantity, varying from three or four pints to six or eight 
quarts in twenty-four hours. It is light in color and of 
high specific gravity, 1030 to 1040, and leaves a whitish 
residue. In summer it attracts flies and has an aromatic 
odor. The total amount of sugar excreted in twenty-four 
hours can be from a few ounces to half a pound or more. 

General. — The most prominent symptoms in childhood 
are loss of flesh and strength. The temperature is normal 
or subnormal and the thirst is unquenchable. The 
tongue and mouth are dry, the bowels are constipated, the 
skin is dry and harsh, and frequently the seat of intense 
itching. This is especially observed at the genitalia 
and may be the first symptom of the disease. There are 
also attending nervous symptoms, such as headache, 
disturbed sleep, enuresis, and abscess formations. ;t 

The course of diabetes mellitus in childhood is very 
rapid, much more so than in the adult, from two to four 
months being the average duration. The disease ends 
in a condition, analogous to uremia, called acetonemia^ 
which is characterized by epigastric pain, dyspnea, a 



CONSTITUTIONAL AND NUTRITIONAL DISEASES 35 I 

fruity odor to the breath, headache, delirium, stupor, and 
coma. 

Nursing. — The room should be light and cheerful. 
Bathing should be frequent. Thirst should be satisfied. 
A specimen of urine should be saved daily unless otherwise 
ordered, and the amount voided in twenty-four hours 
measured. Symptoms of acetonemia must be reported 
immediately. The temperature, pulse, and respirations 
should be taken once a day. 

Diet. — In diabetes the diet is of the utmost importance, 
all sugars and starches must be eliminated as far as 
possible. 

Food-stuffs permissible in diabetes are: cream, curds, 
milk, eggs, buttermilk, fish, oysters, clams, all meats 
except liver, all green vegetables, unsweetened jellies, 
almonds, walnuts, butternuts, and pecans, tea and coffee 
with cream, but without sugar, and plenty of w^ater. 
The bread should be made of gluten flour. 

The food-stuffs that must be avoided are: all sugar, 
potatoes, white and sweet, rice, beets, carrots, turnips, 
peas, and beans. Pastry, unless made with gluten flour, 
and liver. 

It is not necessary that the children should remain in 
bed, unless so ordered by the physician. 

Nutritional diseases 
scurvy, scorbutus, or barlow^s disease 

This is characterized by bleeding, spongy gums, swelling 
and extravasations of blood around the joints, especially 
the knees and the ankles. There may be pseudoparalysis, 
immobility of the legs, extreme tenderness of the skin 



352 DISEASES OF CHILDREN FOR NURSES 

surface with swelling of the body and extremities, a 
thickening of the bones, marked anemia, and weakness. 

Cause. — Prolonged use of condensed milk, sterilized 
milk, and proprietary foods. 

The symptoms may come on slowly and last over several 
months. If the character of the disease is not recognized 
it may prove fatal. 

Treatment. — The disease yields readily to treatment. 
This consists in giving orange juice to the babies; in older 
children lemon juice is used. 

RACHITIS OR RICKETS 

This is a nutritional disease of early childhood, charac- 
terized chiefly by defective formation of the bony struc- 
tures. It usually develops during the first or second 
year; it is not congenital. Poverty, artificial food, and 
bad hygienic surroundings are the predisposing causes. 
Breast-fed children rarely have rickets. The bones are 
soft, being extremely deficient in lime salts, and when 
ossification finally results the bones become heavy, large, 
and irregular in outlines. This causes such deformities 
as bow-legs, knock-knees, spinal curvature, pigeon-breast, 
and square cranium. The liver and spleen are often 
enlarged. The negro race is especially prone to the 
disease. 

Symptoms. — The early symptoms are restlessness 
and slight fever at night, free perspiration about the head, 
diffuse soreness and tenderness of the body, prominence 
of the abdomen, pallor, slight diarrhea, delayed dentition, 
and the eruption of badly formed teeth. 

Skeletal Phenomena. — The head is large and more or 
less square in outline; careful palpation may detect soft 



CONSTITUTIONAL AND NUTRITIONAL DISEASES 353 




Fig. ioo. — Rachitic boy of three years. A large and somewhat angular head. The 
typic posture of a rachitic child, with the arms supported at his side. Curvature of the 
clavicles and the spine causes the neck to appear short. Contraction of the lateral di- 
ameter of the thorax ; abdomen protrudes ; curvature of the bones of the forearm 
(Hecker, Trumpp, and Abt). 

areas in the skull. The fontanel closes late. The sides 
of the chest are flattened, the sternum is prominent; 
nodules can be felt at the sternal end of the ribs called 
^^ rachitic rosary J' There may be a distinct transverse 
23 



354 DISEASES OF CHILDREN FOR NURSES 

groove at the level of the ensiform cartilage called "Harri- 
son^s groove.'^ The spinal column is frequently curved 
anteroposteriorly called kyphosis; or latterly when it is 
termed scoliosis. The long bones are curved and promi- 
nent at the extremities. This prominence leads to en- 
largements at the wrists and ankles. 

The deformities of the legs may be marked. At times 
it is impossible for the child to stand erect and at others 
the whole skeleton is so deformed as to produce rachitic 
dwarfs. The usual deformities are knock-knees, bow-legs, 
and anterior bowing of the tibia. These are corrected 
by operative measures. The bones are broken, set 
straight, and kept in place by the use of plaster casts. 

Prognosis.— Rickets in itself is rarely fatal. Some 
intercurrent disease, like pneumonia, may cause death. 

Treatment. — This consists in giving the affected 
children the best milk obtainable and all the fresh air 
and sunshine they can get. Salt baths, prepared by 
placing three to five ounces of rocksalt in- a gallon of 
water in the baby's tub, and rubbing the child until the 
skin glows, is advantageous. 

Rachitic children should be taught to sit and to lie straight 
on account of the possibility of deformity. For the same 
reason they should not be permitted to walk until this 
danger has passed. 

MARASMUS OR INFANTILE ATROPHY 

When a child is unable to digest and assimilate food 
for any length of time a pathologic condition sets in. 
The symptoms arising from this are grouped under the 
names of malnutrition and marasmus. Marasmus is the 
extreme form of malnutrition, occurring so far as is known, 



CONSTITUTIONAL AND NUTRITIONAL DISEASES 355 

without any constitutional or local disease. It is a re- 
sult of faulty nutrition only. 

The symptoms of marasmus are the same as those of 
malnutrition, only in a more advanced form. They are 
loss of weight until the child literally becomes skin and 
bones, pallor, anemia, and subnormal temperature. The 
appetite in severe cases is almost entirely lost. The 
stools are sometimes normal, but more often contain curds 
and undigested food and are large in comparison to the 
amount of food taken. Bed-sores frequently develop 
and the children die of exhaustion. 

Treatment. — This consists in discovering the food 
which is most easily assimilated and gradually increasing 
the strength of it until the normal percentages are properly 
digested. Such a diet may consist of egg-water, barley, 
arrowroot, and oat-meal water, malted soups, whey, 
buttermilk and milk mixtures, or, in a word, the entire 
subject of artificial feeding. Gavage may be necessary. 

Nursing. — Nutritional diseases are due to a lack of 
proper food, consequently the careful preparation and 
administration of the proper diet is of the utmost impor- 
tance. The character of the stools and vomit should be 
accurately reported and a careful chart of the child's 
weight kept. Bed-sores and pneumonia should be 
guarded against, and the temperature, pulse, and respira- 
tion taken at least twice a day. 



CHAPTER XVII 

INFANT FEEDING 

Nutrition is the most important branch of pediatrics. 
The question whether a child will be strong and robust 
or a weakling is often determined by its food in the first 
three months of its life. The corner-stone of the con- 
stitution is laid during that period. The largest part 
of the immense mortality of the first year is traced directly 
to disorders of nutrition. 

At times temporary success may mean ultimate failure. 
This is illustrated in the use of many of the proprietary 
foods. The results seem to be satisfactory at first, the 
infant gains in weight remarkably, and the absence of 
certain vital elements from the food may not be noticed 
for months. It is finally discovered that the child has 
rachitis or some allied condition and it starts life handi- 
capped by an undermined constitution. Another mistake 
often made is the prolonged use of predigested foods. 
The child is unable to digest naturally the simplest foods 
after prolonged use of such methods, this function being 
undeveloped. Some children with very robust con- 
stitutions seem to thrive on almost any food, but they 
are the exception. 

THE FOOD CONSTITUENTS AND THE PART THEY 
PLAY IN NUTRITION 

This is well described by Holt and in part his descrip- 
tion is given below. " In infancy and childhood, as in 

356 



INFANT FEEDING 357 

adult life, the elements of the food are five in number: 
Proteids, fats, carbohydrates, mineral salts, and water. 
The forms in which they must be served to a child and 
the relative quantities in which they are demanded, are 
different from those required by an adult. One of the 
reasons for this difference is the delicate condition of the 
organs of digestion in infancy, and the inability to assimi- 
late certain forms of food. Another reason is that pro- 
vision must be made not only for the natural waste of the 
body, but for its rapid growth, as it nearly trebles in size 
in the first twelve months. 

** Proteids. — ^These are essential to life since they are 
the only kind of food that is capable of replacing the 
continuous nitrogenous waste of the cells of the body, 
upon the healthy condition of which the digestion and 
assimilation of other elements of food depend. The 
proteid is furnished by the casein and other albuminoids 
found in both the woman's and the cows' milk. It is 
also found in muscle fiber, white of eggs, gluten of wheat, 
etc. The proteids most easily digested by infants are 
those of woman's milk. The greatest difficulty in artifi- 
cial feeding has been to find other proteids to take their 
place. It is the difference in the digestibility of the 
proteids which causes most of the trouble in the substitu- 
tion of cows' milk for woman's milk. The average 
amount of proteid furnished in a good sample of woman's 
milk is 1.5 per cent. 

** Fats. — The uses of fats in the body are intimately 
associated with those of proteids. Fat possesses the 
important property of saving nitrogenous waste, so that 
when this is supplied in the food in proper proportions 
the entire energy of the proteid may be expended upon 



358 DISEASES OF CHILDREN FOR NURSES 

growth and nutrition of the cells of the body, without 
being used up in the production of animal heat. The 
demands upon the proteid by rapid growth of the body 
during infancy make it desirable that whenever possible 
the fats should do the work of the proteid. 

*'In addition to their use as a source of animal heat the 
fats add to the body weight by storing up fat in the body. 
They are needed for the growth of the nerve cells and 
fibers and are essential to the proper growth of bone. 
Fat also fills the role of a natural laxative. The produc- 
tion of fat required in infancy is greater than at other 
periods of life. Probably the most common mistake in 
artificial feeding is to give too little fat. This is one of 
the chief reasons for the failure of proprietary infant 
foods, all being insufficient in fat. Woman's milk of good 
quality contains from three to five per cent, of fat. 

** Carbohydrates. — Although these, like the fats, cannot 
replace the nitrogenous waste of the body, they are impor- 
tant aids to the proteids, and in this respect they are even 
more valuable than fats. The carbohydrates are. partially 
changed into fat and may thus increase the body weight. 
They are capable of replacing the fat waste of the body, 
and are one of the most important sources of animal heat. 
The form in which carbohydrates are furnished to infants 
is milk sugar. 

"In building up the cells of the body the proteids are 
first in importance, the carbohydrates second, and the 
fats third. In production of animal heat the neces- 
sity to maintain life, the fats come first and the carbo- 
hydrates second. The proteids should never be called 
upon for this purpose. In a proper diet all of the ele- 
ments are represented. 



INFANT FEEDING 



359 



** Mineral salts are of greater importance in infancy 
than later in life, on account of the rapid building up of 
the bony system which is going on at this period. The 
most important for this purpose are the phosphate of 
lime and magnesium. These are furnished in abundance 
in both woman's milk and cows' milk. The salts are 
also necessary for cell growth, forming the mineral con- 
stituents of the blood and digestive fluids, and facilitating 
absorption, excretion, and secretion. 

** Water. — The food of all young mammals consists of 
from 80 to 90 per cent, of water. This is needed for the 
solution of certain parts of the food, such as the sugars 
and some of the proteids and for the suspension of other 
proteids and emulsified fats. All the food is thus dis- 
solved and very finely divided, so as to be more readily 
acted upon by the feeble digestive organs of the infant. 
Water is also needed in large quantities for the rapid 
elimination of waste in the body. When the diet of the 
infant is entirely fluid, additional water between feeding 
is unnecessary, but when solids are added and the feedings 
are at longer intervals, water should be given freely 
between feedings at all seasons, but more especially in 



summer." 



WOMAN^S MILK 

This is the ideal infant food. It is the secretion of the 
mammary gland. A few drops may be squeezed from 
the breasts before parturition. Generally speaking, how- 
ever, it is only present after delivery. During the first 
two days the secretion is scanty, but usually upon the 
third or fourth day it becomes established. It is bluish- 
white in color, usually alkaline, sometimes neutral, never 
acid in reaction. The specific gravity is 1031, and when 



360 DISEASES OF CHILDREN FOR NURSES 

precipitated it forms light flocculi, never precipitating in 
large masses, like cows' milk. 

Colostrum. — The secretion in the first two or three 
days differs quite markedly from the later milk. It is 




51G. loi. — Cremometer: The instrument is filled to the mark o with unskimmed 
milk and allowed to stand for from eighteen to twenty- four hours at the temperature of the 
room, when the depth of the layer of yellow cream can be read off in degrees. The num- 
ber of degrees corresponds to the cream percentage, which in good milk should never fall 
below 10 per cent, (after Chevalier). 

of high specific gravity and very rich in proteids and 
mineral salts. 

Composition of Woman's Milk. — Proteids are usually, 
present in proportion of one to two per cent. The amount 
of proteid is larger in the first few days; after the third 
week it is stationary to the end of lactation, when it 
■falls very markedly. 

Fat : 4 per cent, is the average. 



INFANT FEEDING 



361 



Sugar : The ordinary variations are between 6 per cent, 
and 7 per cent. 




s • 


^^^^wFiiW"?yiiiffiiBHI 


CO 2 


! i 1 ^'^ 


|3 


^^^^^^^^^^^^i 4-0 


^4 


■H 0,7% 





4-3 



Fig. 102. 



-Scheme showing the composition of human and of cows' milk: i, Proteid; 
2, fat; 3, carbohydrates; 4, salts (Frvihwald and Westcott). 



Salts : The average proportion is about 20 per cent, 
or about one-fourth that of cows' milk. 



EXAMINATION OF MILK 

The quantity is determined by weighing the baby be- 
fore and after feeding. The average amount of milk taken 
at one feeding by a child is an ounce for each month of 
its age until the eighth month. 

Reaction is obtained by means of litmus paper; specific 
gravity is obtained by means of a small hydrometer. 

Fats. — A cream gauge holding 10 cc. is filled to the 
zero mark, and allowed to stand for twenty-four hours 
at the temperature of the room. Then read off the per- 
centage of cream. The ratio of cream to fat is, woman's 
5 to 3. Cows', after eight to ten hours, 4 to i. 

The sugar and salts are constant. 

Proteids can only be approximately determined by the 
specific gravity and by the percentage of fats. A specific 
gravity higher than 1031 shows increase in proteids; 



362 DISEASES OE CHILDREN EOR NURSES 

lower, a decrease, if percentage of fats is normal. In- 
creased percentage of fats will lower the specific gravity, 
and a decreased percentage will raise it. 

Microscopic examination shows the presence of 

bacteria, etc. 

COWS' MILK 

This is the only milk of lower animals practically 
available for infant feeding. It must be fresh, clean, 
from healthy animals, preferably of a mixed herd rather 
than from a single cow. It is then more apt to be uniform, 
as a single cow is subject to daily variations. Animals 
should have fresh food and transportation should be as 
short as possible. For all practical purposes it is necessary 
that one should know only the amount of fat in the milk 
being used, as this is the only variable factor. 

The Difference between Cows' Milk and Woman's 
Milk. — Cows' milk is more opaque, slightly acid, or 
neutral, but never alkaline in reaction, as is woman's milk. 
There is less sugar in cows' milk, and the proteids in cows' 
milk are not only two or three times as great in amount, 
but they differ in their character. This latter is best 
shown by the digestibility of both proteids by the infant's 
stomach. Cows' milk in the stomach is coagulated into 
large, firm clots, which dissolve slowly, while woman's 
milk forms loose flocculent curds which dissolve readily. 

Cows' milk contains bacteria; woman's milk is sterile. 
. Cream. — A great misapprehension exists as to the 
composition of cream. It is often spoken of as if it were 
entirely different from milk. It should be regarded as 
milk which contains an excess of fat, for the addition of 
cream to a mixture does not change the proteid percentage, 
but only the percentage of fat. 



INFANT FEEDING 3^3 

In infant feeding it is convenient to make use of cream 
containing a definite percentage of fat. This may be 
either 8, 12, or 16 per cent. Sixteen per cent, is most 
often employed. 

METHODS EMPLOYED TO KILL THE BACTERIA IN 

MILK 

Pasteurized Milk. — The bottles, after having been 
thoroughly boiled, should be filled with the prescribed 
quantity of milk and corked with sterilized nonabsdrbent 
cotton. Place the bottles in the cells of the pasteurizer 
and fill the cells with cold water. The cells are then 




Fig. 103. — Freeman's pasteurizer. 

placed in the pasteurizer, leaving out the middle set for the 
convenience of pouring in the boiling water. Next turn 
the faucet of the pasteurizer so that it will be open; then 
pour boiling water into the pasteurizer until it reaches the 
iron rods or until the water begins to run from the faucet; 
then turn off the faucet. Place in position the center 
cells and put the cover on securely. In a half hour 
remove the cover. Attach a hose to cold water faucet 
over the sink and another one to the faucet of the pasteur- 
izer. Place the hose from the cold-water pipe inside the 



364 DISEASES OF CHILDREN FOR NURSES 

pasteurizer between the cells and the sides, turn on the 
cold water, and at the same time turn on the faucet of the 
pasteurizer, so that the water will run out at the bottom 
at the same time that it is running in at the top, thus causing 
a sudden cooling of the bottles, which is very important. 
After the bottles are thoroughly cold remove and place 
in the ice-chest. The pasteurizer should then be emptied 
by the hose attached to the faucet. 

Three important facts must be remembered in pas- 
teurizing milk. First, that the pasteurizer must stand 
on wood or on some other nonconductor of heat. Second, 
that the water poured into the pasteurizer must be boiling 
hot so that the temperature of the milk will be raised to 
167° F. in ten minutes. Third, that the bottles must 
be rapidly cooled. 

To pasteurize milk when no regular apparatus is at hand, 
the bottles should be placed in a basket, preferably one 
made of wire, of which variety there are many on the market. 
A block of wood or a saucer should be placed in the bottom 
of a pan of cold water, and upon this stand the basket 
containing the bottles. This raises the bottles from 
actual contact with the bottom of the pan. 

The water is then heated until the sterile thermometer 
placed in one of the bottles of milk reads 167° F. This 
temperature should be maintained for one-half hour, when 
the botdes should be rapidly cooled under running water 
and placed on ice. 

When sterilizing a thermometer by boiling, be sure to 
have one which will indicate 212° F., otherwise it will 
break. 

Sterilized Milk. — Prepare and fill bottles the same as 
lor pasteurizing. The bottles are then set on a block of 



INFANT FEEDING 365 

wood about one inch thick which is placed in a boiler 
so that the bottles do not touch the bottom. The water 
in the boiler should be then closely covered and allowed 
to steam for one hour. The bottles should then be 
removed, cooled, and put on ice. 

RECEIPTS FOR THE PREPARATION OF INFANT FOODS 

Barley Water. — Cover two tablespoonfuls of pearl 
barley with boiling water, let it boil five minutes, drain, 
and throw water away. Cover with two quarts of boiling 
water and simmer gently until reduced about one quart, 
which takes about two hours. Then strain through four 
thicknesses of gauze. 

The prepared barley flour of the ''Health Food Com- 
pany of New York" or Robinson's Barley, two drams to 
each twelve ounces of water, and cooking for fifteen minutes 
is almost identical with the ordinary barley water (Holt). 



Starch 1-63 1 

Fat 0.05 

Proteid 0.09 

Inorganic salts 03 

Water 08.20 



\ contained in barley water (Holt). 



Total 100.00 



Rice and Oatmeal Water. — Cover two tablespoonfuls 
of rice or oatmeal with boiling water. Let it boil five 
minutes, drain, and throw water away. Cover with two 
quarts of boiling water and simmer gently until reduced 
about one quart. Then strain through four thicknesses 
of gauze. If used alone, add a little salt. 

Rice Milk. — Wash a tablespoonful of the best rice 
and boil it one and a half hours in a pint of new milk. 
Rub it through a fine sieve. Add two tablespoonfuls of 
granulated sugar, heat, and serve. 



366 DIS^EASES OF CHILDREN FOR NURSES 

Albumin and Milk. — Put the white of one egg into 
eight ounces of cold milk. Pour the whole into a fruit 
jar, screw on the top and shake vigorously for half a 
minute. It is then ready to serve. It should be light 
and smooth. 

Albumin Water. — Put the white of one egg into eight 
ounces of cold water. Pour the whole into a fruit jar 
and shake vigorously for half a minute, when it is ready 
to serve. 

Whey. — Heat one pint of milk to 100° F. (no higher), 
add one teaspoonful of rennet and stir gently, stand aside 
to set, but not on ice. After the milk has been thoroughly 
coagulated, stir up the curds with a fork or spoon, and 
strain through a flannel cloth. One quart of milk will 
make about two-thirds or three-fourths of a quart of whey. 

In acute indigestion whey will often be retained when 
other foods are rejected. 

Whey and White of Egg. — To every 7 oz. of whey 
add the beaten white of one egg. 

Whey and Milk or Cream. — In adding milk, cream, 
or a milk mixture to whey, the whey should be made as 
directed above and after all the curds have strained oflf 
the whey should be heated to a temperature of 150° F. 
and the milk, cream, or milk mixture must have been 
pasteurized before adding. 

Whey, Milk, or Cream and White of Egg. — Add the 
quantity of pasteurized milk or cream at the temperature 
and in the manner stated above; then the mixture must 
be cooled or quite cold before adding the beaten whites 
of the eggs, the number of whites being one to every seven 
ounces of whey used, and not one to every seven ounces 
of the mixture. 



INFANT FEEDING 367 

Wine Whey. — Heat a half pint of milk in a saucepan, 
and when steaming hot add, quickly, four tablespoonfuls 
of sherry wine. Let the mixture stand for a few minutes 
on the stove, then take from the fire, break up the curds, 
and strain through flannel or four thicknesses of gauze. 
It may be served with or without sugar. 

Fully Peptonized Milk. — One pint of milk, 4 oz. of 
cold water, i peptonizing powder (5 gr. extract of pan- 
creatis, 15 gr. soda bicarbonate). 

Dissolve the powder in 4 oz. of water and to each 
bottle of milk of 4 oz. (previously pasteurized) add i oz. 
of the mixture. Stand the bottle in a pan of water 
120° F. and allow it to remain there for a half hour, 
when it should be used at once. Peptonize each bottle 
to be used just before it is time for the feeding. Milk, 
fully peptonized, should only be given by gavage or by 
the rectum on account of its bitter taste. All milk ordered 
peptonized and given by gavage or rectum must be fully 
peptonized. 

Partially Peptonized Milk. — One pint of milk, 
4 oz. of cold water, i peptonizing powder (5 gr. extract 
of pancreas, 15 gr. soda bicarbonate). 

Dissolve the powder in 4 oz. of water and to each 
bottle of milk of 4 oz. (previously pasteurized) add i oz. 
of the mixture. Stand the bottle in a pan of water, 120° 
F., and allow it to stand for ten minutes, when it is ready 
to be used at once. 

Feedings of more or less than 4 oz. must be worked on 
the basis of i oz. of peptonizing solution to 4 oz. of milk. 

Peptonized milk is valuable when there is feeble proteid 
digestion. It is not advisable to continue its use indefin- 
itely, as the stomach gradually becomes less and less able 



368 DISEASES OF CHILDREN FOR NURSES 

to do its work. At the most it should be used only for a 
month or two at one time; when stoppage of this method 
is desirable, gradually diminish the amount of powder used. 

Method of Peptonizing Mixtures. — First, make up 
mixture according to the formula. Then add the pep- 
tonizing fluid (made according to the formula) and allow 
the whole quantity of milk to stand in a bottle or pitcher 
in a pan of water, 120° F., for the prescribed length of 
time, say ten minutes or a half hour, according to the 
order. Then quickly raise the water around the milk 
to the boiling-point and allow it to boil for three or four 
minutes. Remove the milk, cool, and bottle, and place 
on ice. The boiling of the water around the milk will 
stop the peptonization which, if not stopped, will cause the 
milk to become very bitter; it also sterilizes the milk and 
does away with the necessity of pasteurizing. 

Oatmeal Gruel. — Mix two rounding tablespoonfuls of 
Bethlehem oatmeal with a little cold water; add a quarter 
teaspoonful of salt. Pour over it one pint of boiling 
water and stir over the fire until it boils. Then stand it 
where it will bubble slowly for a half hour, add a lump 
of sugar and a tablespoonful of whipped cream or a 
tablespoonful of sherry wine, and serve. Children 
seldom care for foods prepared with wine. 

Apple Gruel. — Good in irritation of the bowels. 

Core and quarter a large apple. Pour over it one pint 
of boiling water and simmer until it is reduced to a pulp. 
Strain. Mix two level tablespoonfuls of arrow-root with 
a little cold water and add to the hot apple water. Stir 
until it boils; then move back and let it cook slowly for 
ten minutes. Do not serve too hot and preferably without 
sugar. 



INFANT FEEDING 369 

Farina Gruel. — Put a pint of milk into a double boiler. 
When it comes to the boiling-point sprinkle into it two 
level tablespoonfuls of Hecker's farina. Stir until it 
thickens and then let it cook for twenty minutes. Add 
a quarter of a teaspoonful of salt and a lump of sugar, 
and serve. 

Flour Gruel or Pap. — Put a pint of milk into a double 
boiler and let it come to the boiling-point. Moisten two 
level tablespoonfuls of flour with a little cold water and 
stir into the boiling milk. Add one-fourth of a teaspoonful 
of salt and let it cook for twenty minutes. Add a lump of 
sugar and a little nutmeg if desired. 

German Gruel made with Flour Ball. — Put one 
pint of flour into a strong bag and tie tightly with twine. 
Put into a kettle of boiliag water and boil for five hours. 
When done take off the cloth and peel off the outside 
moist portion. Grate the ball and then put the flour 
into a baking pan and dry in a moderate oven for two 
hours, being careful not to brown. 

Moisten two tablespoonfuls of this flour with a little 
cold water and pour over it one pint of boiling water and 
simmer for three minutes. Add a small pinch of salt and 
a lump of sugar and 4 oz. of warm milk, and serv^e. 

Barley Gruel Liquefied or Dextrinized with Cereo 
or Maltine. — One heaping tablespoonful of barley flour, 
one pint of boiling water. Mix the flour in a small part 
of water and add to the rest. Boil fifteen minutes, then 
add enough cool water to make up the original pint. 
Cool to 100° F. or 105° F. and liquefy with one teaspoon- 
ful of cereo or maltine. This predigests the gruel. 

Barley Gruel. — Moisten one tablespoonful of Robin- 
son's Patent Barley with 4 oz. of cold water; pour over 
24 



370 DISEASES OF CHILDREN FOR NURSES 

it 4 oz. of boiling water and add a half teaspoonful of 
salt. Let it simmer for five minutes; then add 4 oz. of 
hot milk. Let it come to a boil. Stir in a teaspoonful of 
sugar and serve. 

Arrow-root Gruel. — Moisten an even tablespoonful 
and a half of arrow-root in a little cold water. Pour over 
it a pint of boiling milk, stir over the fire until it thickens 
and let it boil slowly for ten minutes. Take from the 
fire and add a teaspoonful of sugar and one-fourth tea- 
spoonful of salt. 

When this gruel is made for a child who is on a weak 
milk mixture, like 3.6.1. or weaker, the gruel should be 
made with two-thirds water and a third milk instead of 
a pint of full strength milk. 

Arrow-root Gruel with Egg. — Separate an egg, beat 
the white and yoke until light; then mix them carefully. 
Add slowly one pint of plain freshly made arrow-root 
gruel, and serve. 

Rice Flour Gruel. — Mix a tablespoonful of rice flour 
with a little cold milk and add it to a pint of scalding milk. 
Cook for fifteen minutes. Add one-fourth teaspoonful 
of salt, a teaspoonful of sugar, one-fourth teaspoonful of 
ground cinnamon, and a teaspoonful of brandy. This is 
especially beneficial as a food in cases of diarrhea. 

Barley Jelly. — Put two tablespoonfuls of washed pearl 
barley into one and a half pints of water and slowly boil 
down to one pint. Strain and let the liquid settle into 
a jelly. 

Barley Jelly made with Robinson's Barley Flour. — 
Dissolve slowly two rounding tablespoonfuls of Robinson's 
barley flour with two ounces of cold water. Add one pint 
of boiling water and simmer gently for fifteen minutes, 



INFANT FEEDING 37 1 

stirring all the time. Strain and let the liquid settle into 
a jelly. 

Beef Juice. — A piece of lean steak is slightly broiled 
on each side and the juice pressed out by a meat press or 
a lemon squeezer. Two or three ounces can ordinarily 
be obtained from one pound of beef. This is seasoned 
with salt and given cold or warm, but not heated suffi- 
ciently to coagulate the albumin in solution. If heated 
above 1 60° F. it will be unfit for use. 

Beef Juice and Milk. — When beef juice is added to 
milk the milk should never be heated above 100° F. 
before the addition of the beef juice. 

Barley Jelly, Maltine, and Milk Mixture. — Dissolve 
two teaspoonfuls of barley jelly (made with Robinson's 
flour) by adding one-fourth teaspoonful of Maltine and 
stirring, After the jelly has become a liquid add to the 
milk mixture in the proportion of the above quantity of 
liquid to every 4 oz. of mixture. 

Preparation of Gelatin in the Treatment of Infan- 
tile Diarrhea. — Five hundred grams (—17 oz., 3 dr. — 
10 grs.) of chemically pure gelatin are dissolved in a Hter 
( — 33 J oz. ) of boiled water; the solution is filtered, and 
after being sterilized for an hour in an autoclave at a 
temperature of 248° F., is poured into tubes having a 
capacity of 10 cc. (— 21^ fldr.), each tube thus con- 
taining I gm. (about 15 gr.) of gelatin. When it is 
desired to use this preparation, it is liquefied by plac- 
ing the tubes in hot water. As much as 12 gm. or 14 
gm. have been given in the course of twenty-four hours. 
Weill commences with 3 gm. a day and increases at the 
rate of i gm. a day until a decided effect is produced. 

Oatmeal Jelly. — Soak two ounces of coarse oatmeal for 



372 DISEASES OF CHILDREN FOR NURSES 

twelve hours in one quart of cold water, then boil the 
mixture down to one pint, and strain while hot through a 
fine cloth or several thicknesses of gauze. 

Malt Soup Mixture. — To make a 40 oz. mixture: 
20 oz. of milk, 20 oz. of water, 3 oz., by measure, of 
wheat flour (measured loosely and not packed), i| oz., 
by measure, of malt soup. 

Number i. — Mix the flour with the 20 oz. of milk and 
suspend it so as to make a uniform mixture. After as 
much of the flour is dissolved or suspended as possible 
strain through gauze (two thicknesses) to strain out all the 
lumps or excess. 

Number 2. — Dissolve the i Joz. of malt in 20 oz. of water. 

Number 3. — Take the first mixture and the second 
mixture, that is, the flour and the milk mixture and the 
malt and the water mixture, and stir them together 
thoroughly. Place the v/hole in an enamel pot (or double 
boiler) and put over a slow fire, allowing the mixture to 
come to 160° F. and keeping it at that temperature for 
twenty minutes, stirring all the time. At the end of the 
twenty minutes bring the mixture to a boil and remove 
from the fire. If there is a loss in the bulk through the 
cooking make up the full amount (40 oz.) by adding 
sterile water; then place in the bottles and cool down 
slowly to the temperature of running water. 

When the mixture is finished it has a light yellow color, 
smells of malt, and when it cools becomes quite thick, but 
when again heated becomes fluid and easily taken through 
the ordinary nipple if the holes are large. 

When the malt soup mixture is ordered one-half or 
one-third strength, it means that instead of taking the 
full amount of milk (that is, the 20 oz.) half or only 



INFANT FEEDING 373 

10 oz. of milk is to be used and the other half is to be 
water, making in the whole mixture, milk 10 oz., water 
30 oz., instead of 20 oz. The extra 10 oz. of water is 
to be added to the 10 oz. of milk, and then the flour is 
dissolved or suspended in the half strength milk or pro- 
ceed as directed above. 

Buttermilk. — At times the proteid in plain cows' milk 
is indigestible even when given in very small percentages. 
Large curds continually appear in the stools. In such 
cases buttermilk often cures the indigestion in remarkably 
short periods of time. 

It should be prepared as follows: 

Flour Sl dr. by weight. 

Sugar 15 " " 

Buttermilk i quart. 

The mixture should be brought to the boiling-point, 
stirring continuously. Just as it is about to boil it should 
be removed from the stove and cooled rapidly under 
running water. The mixture should then be placed upon 
the ice. The proper amount for the age is poured into a 
nursing bottle at feeding time and slightly heated. 

This mixture contains a much higher percentage of 
proteid than diluted cows' milk, but some change takes 
place in it which renders the mixture easily digestible. 
It should not be given for any length of time without the 
addition of cream. 

Buttermilk Conserve. — This is a condensed form of 
buttermilk. One part is added to three or four parts of 
water. It is a very good method of serving buttermilk. 
It should be slightly heated before adding the water. 

Buttermilk tablets are on the market under various 
trade names. If neither fresh buttermilk nor the conserve 
can be obtained, the tablets may be used. 



374 DISEASES OF CHILDREN FOR NURSES 

Condensed Milk. — It is made by heating milk to 
212° F. to destroy the bacteria and then evaporating in a 
vacuum at a low temperature to less than one-fourth its 
volume. 

Condensed milk contains, after diluting six times, about 
I per cent, of fat, 1.20 per cent, of proteid, 7.23 per cent, 
of sugar, and .17 per cent, of salts (Holt). As the usual 
dilution is from twelve to eighteen times it is evident how 
it lacks LQ fats and proteid. Knowing how necessary fats 
and proteids are to the infant it can be appreciated why 
condensed milk should not be used as a permanent food. 
It sometimes works well as a slight change for a short 
period lq acute indigestion, but it should not be used 
permanently without the addition of cream, and never if 
good milk and accurate milk mixture can be obtained. 

Junket. — ^To one piQt of fresh luke-warm cows' milk 
add two teaspoonfuls of essence of pepsin or liquid rennet. 
Stir for a moment and then allow to stand until firmly 
coagulated. It is served cold. 

Kumiss and Bean Flour. — These are preparations 
sometimes used in infant feeding. Kumiss is a fermented 
form of cows' milk. It is more useful for older children 
than for infants. 

Bean flour has been recommended by Edsall for feedings 
in cases of difficult proteid digestion. Especially prepared 
flour must be obtained, and prepared according to the 
physician's instructions. The mixture has a nauseating 
odor, but it has given good results in a limited number of 
cases. 

Protein Milk (Eiweissmilch of Finkelstein) . — The 
object of this preparation is to secure a milk for infant 
feeding which is low in sugar, high in protein, with a 



INFANT FEEDING 3/5 

moderate amount of fat. It is made as follows: To i 
quart of whole milk is added a half ounce of rennet or 
enough to coagulate the casein. The whey is strained 
off through muslin by suspending the curd for one hour. 
The curd is then rubbed through a fine wire sieve. One 
pint of fermented milk (buttermilk, lactic acid milk, 
koumiss, or matzoon) is now added, also i pint of water. 
It is easier to rub the curd through the sieve if the fer- 
mented milk is gradually added during this process. 

The average composition of protein milk is fat, 2.5 per 
cent.; sugar, 1.5 per cent.; protein, 3 per cent.; salts, 0.5 
per cent. 

For prolonged use, maltose should be added. 

INFANT FOODS 

These are not in any way substitutes for mother's or 
properly modified cows' milk. They are capable of doing 
and have done much positive harm. They are the 
greatest exciting cause of rickets and scurvy. At times 
some of the preparations may be of considerable value, 
but chiefly for temporary use in pathologic conditions. 
Here they should be prescribed like drugs. The majority 
of the preparations are rich in sugar and lacking in fats 
and proteids. Children may gain weight, but they do so 
on the carbohydrates alone. The result of such develop- 
ment leads to the waxy appearance which children develop, 
when about a year of age, who have been fed on these 
foods. 



CHAPTER XVIII 
ARTIFICIAL FEEDING 

The various elements necessary for proper food in 
infancy, the difference between mother's milk and cows' 
milk, the various ways of preparing cows' milk to render 
it sterile or more easily digestible, and the various other 
preparations that may be used as substitutes for milk 
were discussed in the previous chapter, so that it is in 
order to discuss the subject of infant feeding proper. 

The different methods of feeding which are available 
are breast-feeding, either by the mother or by a wet- 
nurse ; mixed feeding, or a combination of artificial feeding 
and nursing; and artificial feeding exclusively. 

The first choice should always be maternal nursing. 
This is nature's food for the infant and nature cannot be 
improved upon. 

" While recent advances in artificial feeding have greatly 
diminished the necessity for wet-nursing, there are still 
many instances where, objectionable though they may be, 
they are indispensable for saving the life of the child, as 
the perfect substitute for good breast-milk is as yet un- 
discovered" (Holt). 

By mixed feeding is meant a combination of* breast and 

artificial feeding. This may be resorted to when the 

milk supply of a mother is insufficient, or when the strain 

upon her health is unduly great. The same care must be 

376 



ARTIFICIAL FEEDING 



377 



exercised to keep the nipples clean and to have the feeding 
at regular intervals in breast feeding as in artificial diets. 

Weaning should always be done gradually, when 
possible, for the sake of both mother and child. "While 
there are many women, especially of the lower classes, 
who are able to nurse their children advantageously 
throughout the first year, the number of such among the 
better classes is certainly very small. By the latter 
nursing can rarely be continued beyond the ninth, and 
often not beyond the sixth month, without unduly draining 
the vitality of the mother and at the same time harming 
the child. Weaning in hot weather is usually to be 
avoided. 

" In cases of sudden weaning the food must be very much 
weaker in the beginning than for an artificially fed child 
of the same age. If weaned at six months the child should 
be put on a mixture suitable for a child of one month of 
age; if at nine or ten months, upon a food appropriate for 
a child of three or four months. If this is done the change 
can be made without causing much disturbance. When 
the infant has become somewhat accustomed to cows' 
milk, the strength can be gradually increased" (Holt). 

ARTIFICIAL FEEDING 

In artificial feeding there are several fundamental 
principles which must be constantly borne in mind; they 
are well described by Holt and his work is quoted, in 
part, below: "The food must contain the same con- 
stituents as mother's milk: namely, fat, proteid, sugar, 
inorganic salts, and water; the constituents must be pres- 
ent in about the same proportions as in good mother's 
milk; as nearly as possible the different constituents should 



378 DISEASES OF CHILDREN FOR NURSES 

resemble those of mother's milk both in their chemical 
composition and in their behavior in the digestive fluids'; 
the addition to foods of very young infants of substances 
not found in mother's milk, like starch, is unnecessary, 
contrary to the best physiology, and if used in consider- 
able quantities may be positively harmful. 

'' In the artificial feeding of infants, cows' milk is selected 
because it furnishes all the necessary elements, although 
not in proportions required by young infants. In feeding 
infants according to this plan the attempt is made so to 
modify cows' milk as to make it conform in composition 
to woman's milk, and so to adjust the proportions of the 
various constituents to meet the individual cases. 

"In modifying cows* milk for infant feeding our 
calculations are based upon the composition of good 
breast milk, as determined by the latest analyses: 

Woman's milk, Cows' milk, 

per cent. per cent. 

Fat 4 3-5 to 4 

Sugar 7 4.5 

Proteids 1.5 4 

Salts 2 .7 

Water 87.3 87.3 

(Holt.) 

" In cows' milk there is an excess of proteids and salts, 
too little sugar, and about the quantity of fat required. 
Other conditions which must be considered are the pres- 
ence of bacteria in cows' milk, its acid reaction, and the 
fact that its proteids are more difficult of digestion. 

** Fats. — The average amount of fat that an infant can 
digest varies from 2 to 4 per cent. It is rarely necessary 
in health to go above or below these proportions. Be- 
ginning with the 2 per cent, in the early days of life, this 
can be increased to 3 per cent, in a month, and to 4 per 



ARTIFICIAL FEEDING 



379 



cent, at the age of five or six months. No other mod- 
ification in the fat is necessary. 

** Sugar. — In woman's milk the percentage of sugar is 
constant in all instances, between 6 and 7 per cent. In 
feeding cows' milk it is seldom necessary to have the sugar 
less than 5 per cent, and never more than 7 per cent. 
It should be distinctly understood that the purpose of 
adding sugar to milk is not to sweeten it, but to furnish 
the proper proportion of soluble carbohydrate necessary 
for the infant's nutrition. However, when good milk 
sugar cannot be obtained, cane sugar may be used. The 
amount added must be but little more than half that of 
milk sugar on account of its sweeter taste and its greater 
liability to ferment in the stomach. 

** Proteids. — The modification of the proteids is the 
most important change necessary in cows' milk, for it is 
the proteids which give the greatest difficulty in infant 
digestion. In ordinary cases in health, a reduction in 
the amount of proteids present is all that is necessary. 
The normal amount of proteids in woman's milk is 1.5 
per cent. In very young infants it is necessary to reduce 
it even more than this, sometimes to .75 per cent, and 
even to .50 per cent. By the end of the first month the 
average child can take i per cent, and by the fourth 
month 1.5 per cent, and by the sixth month 2 per cent. 
The reduction of the proteids is effected by dilution with 
water." 

The meaning of such terms as 3.6.1. mixtures etc., is 
3 per cent, fat, 6 per cent, sugar and i per cent, proteid 
mixture. Mixtures should always be expressed in the 
sequence of fat, sugar, proteid. 

** Inorganic Salts. — These, like the proteids, are exces- 



380 DISEASES OF CHILDREN FOR NURSES 

sive in cows' milk and to nearly the same degree. There- 
fore, when milk is diluted as required by the proteids, the 
salts will be nearly in their proper proportion and they 
may be dismissed from separate consideration. 

** Reaction. — The acidity of cows' milk may be over- 
come by the addition of either lime-water or bicarbonate of 
soda. Of the former, 5 per cent, of the total quantity is 
required; of the latter, one grain to each ounce of food." 

The subject of heating milk for the destruction of 
bacteria was considered on page 363. 

Fat is furnished by cream; proteid by milk. Cream 
containing 16 per cent, fat is usually taken as a working 
basis, and a standard solution of milk-sugar of 20 per 
cent, strength should be used. 

Maltose, either in the form of malt soups or in com- 
bination with dextrin, ''dextrimaltose," can be substi- 
tuted for milk-sugar. The quantity of dextrimaltose 
added is the same as would be required when milk-sugar 
is the carbohydrate used. 

It is very much more easily assimilated than other 
sugars. It will, however, break down more readily. 
It should be weighed in determining the proper amount 
to add. A rounded tablespoonful will weigh about \ 
ounce. 

CREAM 

In the larger cities it is possible to obtain certified 
half-pints of cream of 16 and 12 per cent, strengths. 

When these are not available and the nurse has to de- 
pend upon an ordinary quart bottle of milk to obtain the 
cream, she will find the following table of service. 



ARTIFICIAL FEEDING 38 1 

After a quart of milk, containing 4 per cent, fat, has 
stood for at least twelve hours, 

The top 2 ounces represent 24 per cent, cream. 

The " 6 " '' 20 " 

The " 7 " " 16 " 

The " 9 " " 12 " " 

If a pint of milk is used, one-half of the above quantities 
represent the percentages of fat; for example, 3 J ounces 
would equal a 16 per cent, cream, and \\ ounces a 12 
per cent, cream. 

Milk containing 4 per cent, fat is about the average 
quality served to the public. It is not the richest milk 
obtainable, as this is not desired. The cream line of 
certified 4 per cent, milk in the ordinary shaped quart 
milk bottle is about 4 inches below the top, and when 
the visible cream is dipped off it will amount to about 5 
ounces. 

Four per cent, fat milk means that if the quart should 
be shaken until an even distribution of the cream is ob- 
tained there would be 4 per cent, of fat in every ounce of 
milk in the bottle, whether the first or the thirty-second is 
used. 

When milk stands the fat rises to the top of the bottle 
and only the upper ounces contain it; if these should be 
dipped off, the bottom ounces would be entirely free from 
fat ("skimmed milk"). 

It must also be remembered that in obtaining definite 
strength creams, it is not meant that the top 7 or 9 ounces 
should be entirely composed of cream. Both the cream 
and the milk below the cream line must be used. 

This is obtained by two methods : (i) by siphoning, (2) 
by dipping. 



382 



DISEASES OF CHILDREN FOR NURSES 



Method for Siphoning. — A sterile glass tube long enough 
to reach to the bottom of a quart jar and curved at its 
upper extremity is placed in the bottle of milk. To its 
outer end a sterile rubber tube is attached, which runs to the 
sterile receptacle which is to receive the bottom milk. The 
bottom of the bottle of milk must be on a higher level than 
the receptacle. To start the flow of milk introduce a large 
J-ounce sterile eye-dropper into the free end of the rubber 
tube. The bulb of the dropper must be tightly squeezed 




Fig. 104. — Apparatus for siphoning. 

between the fingers when this is done. As soon as the 
dropper is in position release the bulb and the suction will 
draw the milk up the glass tube. Withdraw the dropper 
as soon as the milk has turned the curve of the glass tube. 
If, for any reason, the first attempt at suction is not suc- 
cessful, do not squeeze the bulb again without withdrawing 
the dropper, for if the bulb should be squeezed while 
still in position it would disturb the cream layer. 

Do not start the flow under any circumstances by suck- 
ing with the mouth over the free end of the tube. The 



ARTIFICIAL FEEDING 



383 



mouth is not sterile and would contaminate the end of the 
tube through which the milk flows. The milk is allowed 
to flow until all of the bottom milk is removed from the 
bottle and only the desired amount of top milk remains. 

For instance, to get a 16 per cent, cream, 25 ounces of 
the bottom milk would be siphoned off, leaving 7 ounces 
of 16 per cent, cream. 

Method for Dipping. — A special dipper is necessary, the 
best being a Chapin dipper. 






Fig. 105. — The Chapin dipper (improved form). 



The dipper is introduced open. When the top is on a 
level with milk the bottom is drawn upward, closing 
the dipper, and the first ounce can then be removed 
without spilling or disturbing the cream layer. The 
dipper contains i ounce, and the amount of top milk 
desired is removed by successive dipperfuls. 

Method for Changing Percentages of Cream. — To make 
12 per cent, cream, take two parts of 16 per cent, cream 



384 DJSEASES OF CHILDREN FOR NURSES . 

and one part of whole milk. Example: To make 9 dr. of 
12 per cent, cream, take 6 dr. of 16 per cent, cream and 
3 dr. of whole milk. 

Eight per cent, cream contains one part 16 per cent, 
cream and two parts of whole milk. 

Example: To make 8 per cent, cream, take 2 oz. of 
16 per cent, cream and add 4 oz. of whole milk to make 
6 oz. 

Fats. Sugars. Proteids. 

16 per cent, cream i6 4 3.60 

12 per cent, cream 12 4.20 3.80 

8 per cent, cream 8 4.20 3.90 

The fats alone are increased in cream, the sugar and 
proteid remain practically the same. Cream is the same 
as milk, with the addition of all the fat in the bottle which 
has floated to the surface. 



METHODS BY WHICH MILK CAN BE MODIFIED 
There are several formulae to expedite this work. At the 

Children's Hospital in Philadelphia the nurses construct 

the milk mixtures from the following: 
Baner's Formula. — 

Q = Total quantity to be used in twenty-four hours. 
F' = The per cent, of fat desired in the mixture. 
S = The per cent, of sugar desired in the mixture. 
P = The per cent, of proteid desired in the mixture. 
M = milk. C = cream. L. W. = lime-water. 

Qx(F-P) 

~ = cream. 

percentage 01 cream — 4 

QxP ^ 

— the cream = milk. 

4 
5 per cent, of the total quantity = lime-water. 
Q - M - C - L. W. = sterile water. 

Qx(S-P) 

= milk sugar. 

100 



ARTIFICIAL FEEDING 385 

Example. — A 4.7.2. mixture is ordered, 40 oz. to be 
given in twenty-four hours. The percentage of the cream 
used is 16. 

Q = 4o. F = 4. S = 7. P = 2. 

4ox(4-2) 40x2 

, = = of oz. cream. 

16 — 4 12 ^ 

— (i\= 13^^ oz. milk. 

4 
Y§o of 40 = 2 OZ. lime-water. 
40 - 6f — 13^ — 2 = 18 OZ. of sterile water. 

40x(7-2) 40 X 5 

" = =2 OZ. milk sugar. 

100 100 

The proper proportions for a 4-7-2 mixture, 40 oz. to be 
given in twenty-four hours, based upon i6 per cent, cream 
are: 

Cream 6| oz. 

Milk 13I " 

Sterile water 18 " 

Lime-water 2 " 

40 

Two ounces of dry milk sugar are dissolved in this 
mixture. 

Short Cuts. — In a 3.6.1. mixture the cream equals 
one-sixth of the total quantity, if 16 per cent, cream is 
used ; and the milk equals one-fourth of the total quantity. 

In a 3.6.1. mixture if a 12 per cent, cream, both the 
fat and the proteid are furnished by the cream and the 
addition of milk is unnecessary. 

Example. — Total quantity 32 oz., a 3.6.1. mixture made 
with 12 per cent, cream. 

'?2X(^ — l) ^2X2 „ 

^ '"^ = ^^-^— - 8 oz. cream. 

12 — 4 8 

^^^-8 = o = milk. 
4 

25 



386 DISEASES OF CHILDREN FOR NURSES 

In a mixture where citrate of soda is used the powder 
is added in the proportion of i gr. to each ounce of milk 
or cream. The 5 per cent, of Hme-water is not used in 
such a mixture, the citrate of soda giving the necessary 
alkahnity. 

In using a solution where 2 gr. = i dr., or any other 
solution, the amount of water used to dissolve the necessary 
number of grains should be subtracted from the total 
quantity of sterile water. 

Whenever milk is mentioned, it means whole milk, that 
is, milk that has not been skimmed, and in which a thor- 
ough distribution of the cream has been obtained by shak- 
ing the bottle. 

In diluting the whole milk to reduce the proteid, the fats 
are equally reduced. Therefore, it is necessary to add an 
extra amount of fat to the mixture to bring up its percent- 
age to the proper strength, which is higher than the per- 
centage of proteid desired; for this reason the cream is 
always added to whole milk. 

TOP-MILK MIXTURES 

In private practice it is often more convenient and less 
expensive to use top-milk mixtures instead of adding 
separate standard cream (like 16 per cent, cream) to a 
quantity of whole milk, in order to increase the amount of 
fat in a mixture of cows' milk. 

Cows' milk contains, for all practical purposes, 4 per cent, 
of fat, 4 per cent, of sugar, and 4 per cent, of proteid. If 
I per cent, of proteid is desired, it is readily obtained by 
diluting the whole milk with three times its volume of water, 
this makes the milk one-quarter of its original strength or 
I per cent, proteid. If 2 per cent, proteid is desired, the 



ARTIFICIAL FEEDING 387 

whole milk is diluted with an equal quantity of sterile 
water. This makes the proteid one-half its original 
strength or 2 per cent. The fats and sugars are neces- 
sarily reduced in the same ratio. 

As was said before, the top 7 ounces of a quart of milk 
contain a 16 per cent, cream after standing twelve hours, 
and the top 9 ounces a 12 per cent, cream. The fats alone 
are increased in cream. The proteids are still approxi- 
mately 4 per cent. 

If a 3-6-1 mixture is ordered by the physician, and the 
child is taking ten bottles of 2 oz. each during the twenty- 
four hours, the total quantity for the day would be 20 oz. 
Therefore, it is necessary to make 20 oz. of a mixture 
containing 3 per cent, fat, 6 per cent, sugar, and i per cent, 
proteid. 

Method. — The top 9 oz. should be dipped, or the lower 
23 oz. siphoned, off. This must be carefully done to avoid 
the risk of shaking up the cream and not obtaining the 
fiill strength of fat. This gives 9 oz. of milk containing 
12 per cent, fat, 4 per cent, sugar, and 4 per cent, pro- 
teid. 

If this quantity should be diluted with three times its 
volume of water it would represent 3 per cent, fat, i per 
cent, sugar, and i per cent, proteid, as the milk would be 
only one-fourth of the whole mixture. 

If a 12 per cent, cream is used, and 3 per cent, fat is 
desired, the total quantity should be divided by one- 
fourth. Therefore, J of 20 = 5. Hence, 5 oz. of the 
original 9 ounces of the 12 per cent, cream is the proper 
amount in this example. To this must be added the 
proper amount of lime-water and sugar of milk, which 
may be worked out by Baner's formula, and enough 



388 DISEASES OF CHILDREN FOR NURSES 

sterile water to make the mixture the proper total quan- 
tity. Example: 

I of 20 = 5 ounces of 12 per cent, cream. 

Y^Tj- of 20 = I ounce of lime-water. 

20 X (6 — i) 20 X =; 

■ — — X — = I ounce of sugar of milk, which dis- 

100 100 . 

solves and does not increase the quantity of the mixture. 

Subtracting 6 oz. (top milk and lime-water) from 20 
equals 14 oz. of sterile water necessary to complete the 
mixture. Thus: 

Top milk 5 ounces 

Lime-water i ounce 

Sterile water 14 ounces 

20 " 

Sugar of milk i ounce, which dissolves. 

The 5 oz. represent \ of 20, the dilution being 15 oz., 
so the fat is 3 per cent, and the proteid is i per cent. 
The sugar, which was reduced to i per cent, by this dilu- 
tion, is raised to 6 per cent, by the addition of the ounce 
of sugar of milk. 

That the top 9 oz. contain practically all the fat in the 
quart of milk can be proved by multiplying 9 by the 

percentage of fat and dividing by 100: ^ ^— = 1.08 



ounces of fat in 9 ounces, and then subtracting this 
amount from the total quantity of fat in 32 oz. of a 4 per 

cent, milk, ^ 1.28 ounces of fat in a quart, which 

subtraction leaves .20 oz. of fat in the remaining 23 oz. 
of bottom milk, which is practically skimmed milk, and 
the addition of any amount of these bottom 23 oz. to a 
mixture would not raise the percentage of fat, but only 



ARTIFICIAL FEEDING 389 

the proteid. Therefore, if a 3-6-2 mixture is desired, it 
is only necessary to add some of the bottom milk to bring 
up the percentage of the proteid. 

Thus, 20 oz. of a 3-6-2 mixture are desired. 

From the previous example we know the quantities 
necessary to make a 3-6-1 mixture. 

By dividing the total quantity by \ we get the proper 
dilution of the fat to 3 per cent., but the proteid is 
likewise reduced to i per cent. Here it is necessary to 
raise the proteid to 2 per cent. This can be done as 
follows: 

If whole milk contains 4 per cent, of proteid, diluting 
with an equal amount of sterile water would give a 2 per 
cent, proteid, but we have already diluted with three parts 
of water, reducing the proteid to i per cent., therefore, by 
adding an amount of skimmed milk equal to the quantity 
of top milk used, we will double the percentage of proteid 
without disturbing the fat, consequently the result would be: 

Top milk 5 ounces 

Bottom milk 5 " 

Lime-water i ounce 

Sterile water 9 ounces 

Sugar of milk i ounce, which dissoives. 

One-half the mixture is milk and cream and one-half 
water. 

In this same manner any percentage of proteid can be 
worked out if it is remembered that one-quarter of the total 
quantity represents i per cent, of proteid. 

Thus, if I J per cent, of proteid is ordered in a 20-oz. 
mixture, and 5 oz. represent i per cent., it would be 
necessary to add 2J oz. of bottom milk. 

As it is only possible to obtain 9 oz. of 12 per cent, 
cream from i quart of milk, anything above 36 oz. of total 



390 DISEASES OF CHILDREN FOR NURSES 

mixture will require the purchase of an extra pint or 
quart of milk. 

For fat percentages lower than 3 per cent., it would be 
necessary to take smaller fractions; thus, one-sixth of the 
total quantity would represent a 2 per cent, fat if a 12 per 
cent, cream is used. The proteid would be reduced to 
two-thirds of i per cent., and sufhcient bottom milk would 
have to be added to bring up the percentage. 

Example. — If 24 oz. of a 2-6-1 mixture is ordered: 

One-sixth of 24 oz. equals 4 oz. of top 12 per cent, milk, 
representing 2 per cent, of fat and two-thirds of i per cent, 
of proteid. 

If two-thirds of i per cent, is contained in 4 oz., i per 
cent, will be represented in 6 oz. c 

f:I::4:x = 4-^-f = 6 ounces. 

Therefore, 2 oz. of bottom milk must be added. The 
formula would then read: 



Top milk 4 ounces 

Bottom milk 2 " 

Lime-water 13^ " 

Sterile water i6f " 

Sugar of milk i-j ounces, which dissolves. 



The quantity of lime-water and sugar of milk are de- 
termined by Bauer's /(9fww/a. 

Another method which can be used to arrive at the same 
result is to work with two bottles of milk. If the amount 
to be used is small, two pint bottles will answer. 

The top 3 J oz. of milk in a pint represent a i6 per cent, 
cream. This amount can be dipped off and the quantity of 
16 per cent, cream found necessary by Bauer's formula 



ARTIFICIAL FEEDING 39 1 

can be added to the amount of whole milk required. 
The whole milk is obtained from the second botde, which 
has been thoroughly shaken to get a uniform distribution of 
the cream. A 12 per cent, cream can be obtained by 
using 4 J oz. Two quart bottles can also be used when the 
quantities required cannot be furnished by the pints. 
Example. — Forty ounces of a 4-7-2 mixture are desired: 
The top 7 oz. of a quart give a 16 per cent, cream. 
Working with Baner's formula we find that 6f oz. of a 16 
per cent, cream are necessary; therefore this amount is 
taken from the top 7 oz. and added to 13J oz. of whole 
milk taken from the second bottle, which amount is found 
to be the proper quantity to add to this mixture by working 
the formula (see page 384). 

CALORIC METHOD OF INFANT FEEDING 

This is a method based upon the energy requirements 
of the average infant in health. 

Calorie is the term used to represent units of energy; 
it is the amount of heat required to raise i kilogram of 
water 1° C. in temperature. 

In feeding infants and children the practical value of 
this method lies in the fact that it enables one to see 
if he is feeding far above or below the physical re- 
quirements, and it furnishes a good check to other 
methods. 

The caloric values of the different ingredients in an 
infant's diet have been carefully calculated; the factors 
9.3 represent fat; 4.1, sugar; and 4.1, proteid. Multiply- 
ing these known values by the amount of each ingredient 
taken, the total caloric value of the diet can be estimated. 
The results will be approximately as follows: 



392 DISEASES OF CHILDREN FOR NURSES 

1 ounce of 7 per cent, milk has a caloric value of . . 27.5 

I ounce of 6 per cent, milk has a caloric value of 25.0 

I ounce of 5 per cent, milk has a caloric value of 22.5 

1 ounce of 4 per cent, milk has a caloric value of 20.0 

I ounce of 3 per cent, milk has a caloric value of. ... 17.5 

I ounce of 2 per cent, milk has a caloric value of . . , 15.0 

I ounce of i per cent, milk has a caloric value of 12.5 

I ounce of fat-free milk has a caloric value of . . . lo.o 

I ounce of whey has a caloric value of lo.o 

I ounce of milk-sugar, by weight, has a caloric value of 116.0 

I ounce of milk-sugar, by volume, has a caloric value of . . . 72.0 

I even tablespoonful of milk-sugar has a caloric value of 44.0 

I ounce of barley flour, by weight, has a caloric value of loo.o 

I ounce of barley water (i tablespoonful to a pint) has a caloric 

value of 2.0 

I ounce of malt soup extract has a caloric value of ............ . 80.0 

I ounce of condensed milk has a caloric value of 132.0 

I ounce of olive oil, by volume, has a caloric value of 245.0 

—{Roli). 

The caloric value of any modification of cows' milk of 
known percentages may be calculated as follows: 

An infant is taking six feedings of 6 ounces, or 36 
ounces daily, of a milk containing fat, 3.5 per cent.; 
sugar, 7 per cent.; protein, 1.75 per cent.: 

.035 (fat %) X 9.3 (caloric value of fat) = 

.07 (sugar %) X 4.1 (caloric value of sugar) = 
.0175 (protein %) X 4.1 (caloric value of protein) = 

.325 caloric value of fat in i gram of food. 
.287 caloric value of sugar in i gram of food. 
.072 caloric value of protein in i gram of food. 
.684 caloric value of i gram of food. 

.684 X 100 = 684 (caloric value of i liter of food); 
36 ounces — 1.06 liters; 
1.06 X 684 = 725 (number of calories in food taken daily). 

The average infant in health requires about 100 calories 
for each kilo {2\ pounds) of body weight from the third 
week to the sixth month. These gradually diminish 
until at the end of the first year they are about 75 to 80 
calories per kilo. 

The caloric requirements are greater in very active 
infants, premature babies, and those much below the 



ARTIFICIAL FEEDING 393 

average weight. For such infants 125 to 150 calories per 
kilo may be necessary. 

Throughout the years of childhood they need about 80 
calories per kilogram. The adult, moderately active, 35 
to 40 calories per kilogram, and the very aged about 27 
calories per kilogram. 

In the undernourished child a higher caloric require- 
ment is needed. This may follow an illness or be due to 
improper dieting. 

Appended is a table worked out by Dr. Clifford B. Farr, 
of Philadelphia, which is especially useful, since it is con- 
structed on the basis of a definite caloric valuation. He 
gives the weight of the substances described which it re- 
quired to produce 100 calories, or fractional parts thereof. 

In a given case, knowing the total caloric requirement, 
it is easy to calculate from this table how much of each 
article of food must be given to gain the desired result, 
and by adding together the caloric values of the quantities 
of each ingredient used the total caloric value is quickly 
estimated. 

The first column represents the weight in grams; the 
figures in parentheses, ounces avoirdupois. In the case 
of liquids the bulk in fluidounces is added: 

Calories. Article. Weight. 

100 Steak, Tenderloin* 35 gf- (i-3) 

100 Beef, scraped, t (Round, cooked, lean) . 54 (2) 
100 Panopepton.t Largest dose recom- 
mended, 15 c.c . 140 c.c. 5 oz 

100 Chicken, Roastf 55 (2) 

100 Halibutf. 83 (3) 

50 Oysters (raw on shell) , . 96 (3.4) 

100 Bacon (raw) 15 (.5) 

25 Consomme 207 (7.3) — 7 fl. oz. 

* Locke, Food Values, New York, 1911. 

t Atwater and Bryant, Bull. 28, Dept. Agriculture. (Also indirectly 
for analyses given by Fisher and Locke.) 
X New and non-official remedies. 



394 



DISEASES OF CHILDREN FOR NURSES 



Calories. Article. 

25 Beef-juice , . 

Warm process* . . . 

12.5 Beef-broth* 

P. 1.02. , . . 

25 Beef-juice. 

Cold process* ....................... 

P. 3.00. ................ 

100 Yolks {a)\ 

(a) I bulk, 6 to 7 caloric value. 

75 Boiled egg (small) (6) 

(6) Shell, II per cent, gross weight. 
100 Egg white (c) from 7 eggs, 26 gm. each. . 
(c)| bulk, 1-7 caloric value. 
25 Albumen-water,* double strength ...... 

2 whites to 8 oz 

(52 g: egg white) 

25 Asparagus (canned) .................. 

50 Green peas (canned) .................. 

25 Lettuce. 

100 Lima beans f (cooked) 

100 Potato (baked) 

50 Spinach (cooked) 

25 Tomatoes (canned) 

100 Baked beansf (home-made) ........... 

100 Pea soupt (split) . . . 

100 Figs 

50 Apples (raw) 

100 Bananas. 

50 Orange juice 

IOC- Olives (green) 

100 Almonds 

100 Peanuts 

100 OHve oil .... , 

100 Sponge cake 

100 Baked custard, f egg, milk, sugar 2, 2 

tablespoonfuls, \ cup 

100 Sugar, granulated or lump 

100 Maple syrup 

100 Milk-sugar, 2 even tablespoonfuls 

100 Home-made white bread 

100 Rolls, French or Vienna 

100 Shredded wheat 

100 Zwiebach 

100 Graham crackers (3) 

100 Soda biscuits (4)! (Uneeda) 

100 Rice (raw) . 

100 Rice (boiled) (5 fl. oz.). 

100 Rice (flaked) (9 fl. oz. by bulk). 



Weight. 

150 

5.3 oz.— 5^ fl. oz. 
312 

1 1. 1 oz. — loj fl. oz. 
200 
7.1 oz. 
7 fl. oz. 
27 (i) — I fl. oz. 

45 (i-6) 
181 (6.4)— 6i fl. oz. 



200 



7.1 oz. 
7 fl. oz. 



135 
89 

126 
62 
86 

87 
108 

50 
77 
31 
103 
100 
94 
32 

15 
18 
II 

25 

73 
24 
35 
25 
38 

35 
27 

23 
23 
24 
28 



-3|fl. 



oz. 



4-9) 
3-1) 
4.5) 
2,2) 

3.0) 

3-o) 

3.8)-3.i fl. oz. 

1.8) 

2.8)— 2f fl. 0Z-. 

I.l) 

3.6) 

3-5) 

i.i) 
0.5) 
0.6) 
0.4) 
0.9) 



2.6) 
0.86) 
2)- 
0.9) 

1.3) 
1.2) 
0.9) 
0.8) 
0.8) 
0.9) 
i.o) 



fl. oz. 



■i\ fl. oz. 



* Holt, Diseases of Infancy and Childhood, 5th ed. 
t Locke, Food Values, New York, 1911. 



ARTIFICI'AL FEEDING 395 

Calories. Article. Weight. 

100 Cream of wheat (wheat flour) 27 (i.o) 

100 Cream of wheat (prepared) (6 fl. oz. by 
bulk). 

100 Oatmeal (flaked) 25 (0.9) 

100 Oatmeal (prepared). 

25 Barley water* 337 

Tablespoonful to pint 12 oz.; 11 fl. oz. 

ioo» Wheat or barley flour 27 (i.o) 

100 Cheese, American 22 (0.8) 

100 Butter. 13 (0.5) 

100 Woman's milk,* 1.50; 4; 7 . 140 c.c; 5 oz. Av.; 

5 fl. oz. 

100 Cows' milk* (average) 140 c.c. 

3-50; 4; 4-50 5 oz.; 5 fl. oz. 

100 Cows' milk (rich)* 127 c.c. 

3-50; 5; 4-50 4.5 oz.; 4^ fl. oz. 

100 Cream, 16 per cent.* . 56g. 

3.25; 16; 4.05. 2 oz.; 2 fl. oz. 

100 Cream, 20 per cent.* 47 c.c. 

3-o'5; 20; 3.90 ....:.. 1.7 oz.; if fl. oz. 

100 Cream, 4.0 per cent.* ................. 25 ex. 

2.20; 40; 3.00 0.9 oz.; I fl. oz. 

100 Top-milk, 7 per cent.* io2g. 

3-50;. 7; 4.5?- • • • . . 3-6 oz.; zl fl-oz-. 

100 Skimmed milk* (1.80 per cent.) 2oog. 

(6 oz. removed from a quart of 4 per 

cent.), 3.60; 1.80; 4.50 7.1 oz.; 7 fl. oz. 

From 10 per cent, milk, with addition 
of milk-sugar ,* 

100 0.50; 1.50; 5.50. ...... 256 c:c:; 9.1 oz.; 

8| fl. oz. 
From 7 per cent, milk, with addition 
of sugar,* 

100 1.25; 2.50; 6.50 i8ig.; 6.5 oz.; 

6| fl. oz. 
From 4 per cent, milk, with addition 
of sugar,* 

100 2.50; 2.80; 5.50. 169; 6 oz.; 6 fl. oz. 

From skimmed milk (1.80), with sugar,* 

100 1.20; 0.60; 7.00. . 256g.; 9.1 oz.; 8| fl. oz. 

100 Condensed milk* 33g. 

(Eagle brand) 1.2 oz. 

8.43 ; 6.94; 50.69 I fl^. oz. 

100 I with 6 of water 231 (8*3) 

1.20; 0.99; 7.23 7I fl. oz. 

100 I with 9 of water 322 

0.84; 0.69; 5.1 II. 5 oz.; lof fl. oz. 

100 Koumiss from cows' milk 220 

2.66; 1.83; 4.09 8 oz.; 7I fl. oz. 

100 Buttermilk* 278 

3.60; 0.50; 4.06 9.9 oz.; 9 fl. oz. 

TOO Whey (from whole milk)* 285; 10 oz.; 95 fl. oz. 



39^ DISEASES OF CHILDREN FOR NURSES 

METHODS FOR DETERMINING THE PERCENTAGES OF 
VARIOUS MIXTURES 

Whole cows' milk contains 4 per cent, of fat, 4.5 per 
cent, of sugar, and 4 per cent, of proteid. 
Milk and Lime-water, 5 to i. — 

f of the mixture is milk, 
f of 4 per cent. = -\° = 3^ per cent, of fat. 
•f of 4^ per cent. =Tf = 31 P^r cent, of sugar. 
|- of 4 per cent. = Y" = 33 P^r cent, of proteid. 

Therefore, this mixture contains 3 J per cent, of fat, 
3I per cent, of sugar, and 3J per cent, of proteid. 

Milk and Lime-water, 3 to i. — The percentages are 
determined in the same way, three-fourths of the whole 
quantity being milk. 

Whey, 5 oz. + 1 oz. of a 16 Per Cent. Cream. — 
Whey contains 0.32 per cent, of fat, 4.79 per cent, of 
sugar, and 0.86 per cent, of proteid. Cream contains 
16 per cent, of fat, 4 per cent, of sugar, and 3.6 per cent. 
of proteid. 

In this mixture one-sixth of the total quantity is cream. 

\ of 16 per cent. = -^g-=2.66 per cent, of fat contained in cream, 
f of .32 per cent. = ', = .26 per cent, of fat contained in whey. 

2.92 per cent, of fat contained in mixture. 
^ of 4 per cent. = f = 0.66 per cent, of sugar contained in cream. 

\ of 4.79 per cent. = -^ == 3-99 per cent, of sugar contained in whey. 

4.65 per cent, of sugar contained in mixture. 
.60 per cent, of proteid contained in cream 

f of .86 per cent. = "^^5"= -71 per cent, of proteid contained in whey. 



\ of 3.60 per cent. = ■ ^ = .60 per cent, of proteid contained in cream. 



6 
4JO 



1.3 1 per cent, of proteid contained in mixture. 

The mixture contains 2.92 per cent, of fat, 4.65 per 
cent, of sugar, and 1.31 per cent, of proteid. 

Rule for Determining the Percentage of Fat in a 



ARTIFICIAL FEEDING 397 

Mixture. — Add the quantities of the ingredients together. 
Multiply the percentage of the fat in the cream by the 
quantity of cream in the mixture and divide by the total 
quantity. Multiply the percentage of fat in the milk by 
the quantity of milk in the mixture and divide by the 
total quantity. The sum of the two results gives the 
percentage of fat in the mixture. 

Example. — In a mixture containing 5 oz. of a 16 per 
cent, cream, 11 oz. of milk (4 per cent, fat) and 24 oz. 
of water, the total quantity is 40 oz. 

= in = 2 per cent, of fat in the cream. 

40 

f^ = 1,1 per cent, of fat in the milk. 



40 



3.1 per cent, of fat in the mixture. 

Therefore, the mixture would contain 3.1 per cent, 
of fat. 

CARE OF MILK IN THE HOUSE 

The best milk may be absolutely spoiled by carelessness 
in the methods employed for keeping it in the house. 
Too often in the large cities the bottles are left at the front 
or back door by the distributor at a very early hour in the 
morning. Two or three hours often pass before the milk 
is placed on ice; this may be during the hottest days of 
summer, and often after it has stood in the direct rays 
of the sun. Necessarily the milk should be placed imme- 
diately in the refrigerator. Some very ingenious devices 
are constructed by many to receive the milk and save the 
early morning rising, at the same time having the milk in 
proper surroundings. If the milk is not delivered in 
hermetically sealed bottles then nothing is better to keep it 
in than an ordinary mason jar which has been properly 



398 DISEASES OF CHILDREN FOR NURSES 

sterilized. The milk should not be allowed to stand in 
the refrigerator uncovered; nor should it be placed in the 
same compartment with the food. The best method to 
employ, if a separate compartment is not available, is to 
have a small refrigerator for the milk alone; many of 
these are on the market. However, a very satisfactory 
one can be improvised from an ordinary bread-box. 
The refrigerators must be kept scrupulously clean. If at 
any time. there is a disagreeable odor perceptible upon 
opening the box, it is either due to neglect or to a leak into 
the packing between the walls of the refrigerator. As 
this packing is often hair, wool, or some similar substance, 
the water renders it mouldy and consequently unhealthy; 
when such a contingency occurs the refrigerator should 
be immediately abandoned. After the milk is on the ice 
it should be disturbed as little as possible, hence it is 
better to prepare the milk for the day at one time. Each 
feeding should be placed in a separate nursing bottle 
properly sterilized and stoppered with aseptic cotton. 
These bottles are placed in the refrigerator immediately. 
It is better to have the ice in a separate compartment from 
the milk, as the water which collects fom the melting of 
the ice is not pure, often containing dirt, and if from 
artificial ice, traces of ammonia. If, for any reason 
at all, a nursing bottle should topple over into this water, 
the milk within it may become contaminated. It is well 
to have the bottles stand in a wire frame. 

Milk left uncovered for fifteen minutes may render 
all the care and aseptic measures practised at the dairies 
useless. 

The same care must be used in handling condensed 
milk and buttermilk. All can openers used to open tins 



ARTIFICIAL FEEDING 399 

containing the commercial varieties of these products 
must first be boiled. The entire contents of the can 
must be emptied into a sterile nursing bottle or some 
similar receptacle and kept on ice. Precautions must be 
taken to prevent contamination by placing sterile cotton 
in the mouth of the bottle and covering other forms of 
receptacles thoroughly. If a can of condensed milk is 
slightly warmed, by placing it in hot water for five minutes, 
the contents will run easily into a nursing bottle. Con- 
densed milk that has been open for more than two days 
should not be used. 

Be careful to keep the cotton stoppers sterile while 
filling the bottles; do not carelessly place them where they 
may be contaminated. 

All vessels in which milk has stood for any length of time 
should be thoroughly scalded before refilling. 

Milk should not be kept warm in Thermos bottles or by 
any other method for any length of time. It favors the 
growth of bacteria. Even when pasteurized milk is so 
kept it permits the spores to develop. When milk is 
pasteurized all living bacteria are killed, but the spores 
("the eggs" from which bacteria develop) are not de- 
stroyed. 

The nurse's hands should be thoroughly scrubbed before 
preparing milk mixtures and before feeding the children. 

BOTTLES AND NIPPLES 

The best style of bottle is that which can be most 
easily cleaned. On no account should bottles with any 
complicated apparatus be allowed. The cylindric bottles 
with wide mouths are generally preferred. The best 
nipples are those of plain black rubber which slip over the 



400 DISEASES OF CHILDREN FOR NURSES' 

neck of the bottle. Those with long rubber tubes going 
to the bottom of the bottle should not be used, as it is 
practically impossible to keep them clean. The hole in 
the nipple should be large enough to allow the milk to 
drop rapidly when the bottle is inverted, but not so large 
as to permit the milk to run through in a stream. 

The bottles should first be rinsed with cold water, then 
washed with hot soapsuds and a bottle-brush. When not 
in use they should stand full of water. Before the milk is 
put into them they should lie for twenty minutes in 
boiling water. After the bottles have been sterilized they 
should not remain uncovered, but should be stoppered 
immediately with sterile cotton. 

Nipples should be boiled for five minutes daily, and 
when not in use they should be kept in a receptacle con- 
taining a saturated solution of boric acid. 

To prevent nipples from collapsing, the nursing bottle 
should be held at such an angle so that the nipple is con- 
stantly filled with milk. If for any reason a nipple is 
removed while feeding, do not put it down carelessly; 
it is better to drop it into the receptacle containing boric 
acid. 

RULES FOR FEEDING 

A child should not be more than twenty minutes taking 
its food, and should not be allowed to sleep with the 
nipple in its mouth. The botde should be placed so 
that the child sucks milk, and not air. 

The bottle of milk should always be warmed to a 
temperature of ioo° F. before feeding. This is done by 
placing the bottle in water, which is heated until the de- 
sired temperature is obtained. One of the handiest and 



ARTIFICIAL FEEDING ^0\ 

quickest methods of heating milk is by using a "Bubble 
quick." This is a patented apparatus which can be ob- 
tained in most of the large cities. 

If there is regurgitation immediately after feeding, sit 
the infant upright. Often there will be an eructation of 
gas which will eliminate this tendency. 

A child should never be jumped up and down or rocked 
while it is being fed or immediately afterward. 

Children should be kept quiet after their evening meals 
to avoid the occurrence of night terrors. 

Schedule for Feeding Healthy Infants During the First Year. 

Number of Interval be- Night feed- Ounces Ounces 

A „_ feedings in tween meals ings: lo p.m. for one for twenty- 

^ twenty-four by day. to 7 a.m. feeding. four hours, 

hours. Hours. 

3d to 7th day 10 2 2 I to i| 10 to 15 

2d to 3d week 10 2 2 i^ to 3 15 to 30 

4th to 5th week 9 2 i 2| to 3I 22 to 32 

6th week to 3d month. 8 i\ i 3 to 4 J 24 to 36 

3d to 5th month 7 3 i 4 to 5 J 28 to 38 

5th to 9th month. ... 6 3 o 5l to 7 33 to 42 

9th to 1 2th month 5 3I o 7l to 9 37 to 45 

(Hoh.) 

Usually the child's food in health should be increased 
in strength just as fast as the child's digestion will permit. 
An infant much above the average in weight must have 
its food graded accordingly. With this knowledge artifi- 
cial feeding in health resolves itself iato an easy problem. 

Indications for Varying Mixture. — In regard to the 
exact indications when the fats, sugar, and proteids of 
milk are to be varied in infant feeding, much is yet to be 
learned; however, the following are the chief points: 

Sugar. — If the sugar is too low, the gain in weight is 

slower than when it is furnished in proper amounts. 

Excess of sugar is shown by colic, or thin, green, and 
26 



402 DISEASES OF CHILDREN FOR NURSES 

very acid stools, which cause irritation of the buttocks. 
Sometimes eructations and regurgitations of small quan- 
tities of food take place. 

Fat. — Excess of fat is shown by vomiting or regurgita- 
tion of food in small quantities, usually one or two hours 
after feeding; sometimes by frequent stools which are 
almost normal. There may be fat lumps in the stools. 

Too little fat causes constipation, and dry and hard 
stools. 

Proteids. — Excess of proteids is shown by the presence 
of curds in the stools, by colic, constipation, and vomiting. 

Excess in quantity of milk given at a feeding causes 
immediate regurgitation. 

It is not practicable to modify the milk so as to meet 
every temporary symptom of discomfort an infant may 
have. The general rules are; 

If they are not gaining in weight without special signs 
of indigestion, increase the proportions of all the ingre- 
dients. 

If there is habitual colic, reduce the proteids. 

For frequent vomiting, soon after eating, reduce the 
quantity. 

For the regurgitation of sour masses of food reduce the 
fat and also sometimes the proteids. 

For obstinate constipation increase both fat and proteid. 



THE USE OF FOODS OTHER THAN MILK DURING THE 

FIRST YEAR 

The addition of other foods should be deferred until 
after the eighth or ninth month. Starch can then be 
added, usually in the form of barley. As starch is added, 



ANTIFICIAL FEEDING 403 

sugar should be gradually withdrawn. The only other 
thing to be advised during the first year is beef juice; this 
may be given after the tenth or eleventh month to weak 
infants; at first only \ oz. daily; later 3 oz. 

In difficult cases of feeding the problem is essentially 
the same: that the food must be adapted to an infant 
whose powers of digestion are very feeble and easily dis- 
turbed. 

The general principles to be followed in these cases 
are to give larger quantities of diluted food after three 
months of age, to feed at more frequent intervals, and 
since the proteids give the most trouble, the fats coming 
next, to reduce the strength of these elements. Sugars 
rarely cause trouble; therefore, it is seldom necessary to 
reduce them. Hence such formulae as 2, 6, .75 are often 
seen. 

Another plan that may be followed when the infant 
has great trouble in digesting the proteids of cows' milk 
is to peptonize it, or to add some such ingredients as 
oatmeal, arrowroot, or barley. These may take the place 
of some of the plain boiled water of the formulae previously 
given. The number of cases that cannot be managed by 
simply varying the elements of cows' milk is small. 

The scales are the best means of deciding whether a 
child is progressing favorably. At first the gain in weight 
will be slow — 2 or 3 oz. a week; later, however, they 
should gain about 8 oz. a week. For those children 
who do not thrive on intelligent modification of cows' 
milk sometimes the substitution, for a short period, 
of condensed milk succeeds; sometimes they thrive upon 
sterilized milk, malted soups, or broths and bean flour, 
withholding the milk for a time. In every instance the 



404 DISEASES OF CHILDREN FOR NURSES 

general principle must be to begin with something which 
the child can digest and assimilate, and return to the usual 
proportions of the milk ingredients gradually, but just 
as soon as possible. 

Most proprietary foods are composed almost entirely of 
carbohydrates and are insufficient in fats. 

Throughout childhood, in all acute febrile diseases, the 
rule should be less food and more water. 

When a child for any reason refuses to take its food, 
and there is danger of death from inanition, gavage should 
be practised. 

In acute diarrhea in infancy stop the mixture and 
give barley water for twenty-four hours; purge and 
return slowly to normal mixture. 

FEEDING DURING AND AFTER THE SECOND YEAR 

OF LIFE 

The average child, when it reaches the age of twelve 
months, can take plain milk without any addition of 
water, or milk with the addition of small quantities of 
water. The child should weigh about twenty pounds, 
be about twenty-nine inches in length, have six teeth, and 
during the second year begin to walk around a chair. 

The child should be vaccinated during the second 
year, if this has not been done earlier. It should be 
taught to make known when it desires to urinate or to 
have a bowel movement, and to have them at convenient 
and regular periods five or six times a day. The foreskin 
of a boy should be retracted daily until there is no trouble 
in pulling it back. This prevents trouble later. 

A child should have a healthy complexion, a clean 
tongue, and well-digested bowel movements. 



ARTIFICIAL FEEDING 405 

To feed children too often, with too many kinds of 
food and with too 'little milk, during the second year, is a 
mistake. 

A child of twelve months should be fed five times a 
day, say at 6 o'clock in the morning, 10, i, 5 and 9 
p. M. Often a simple milk diet will be sufficient, 
the milk being given plain or with small quantities of 
water added. Eight ounces at a feeding is enough. In 
addition to this 4 oz. (eight tablespoonfuls) of gruel and 
two teaspoonfuls of orange juice can be added to the i 
o'clock meal. Orange juice is always a good thing to 
give children, as it prevents scurvy. It can be given 
after the age of six months. The best gruel is oatmeal. 
Do not give this instead of milk, but in addition to the 
milk. 

At twelve months a child's diet should be: 

6 A. M., 8 oz. of milk. 
ID A. M., 8 oz. of milk. 
I p. M., 8 oz. of milk, 4 oz. of gruel, \ oz. of orange juice. 
5 p. M., 8 oz. of milk. 
9 p. M., 8 oz. of milk. 

Other food than milk should be taken from a spoon. 

The teeth that a child has at twelve months are not 
chewing teeth; therefore, no solid food should be given. 
Children do not have chewing teeth until they are twenty 
months old. 

At fifteen months of age a soft boiled egg can be added 
at the I o'clock meal, and the gruel increased to 6 oz., 
given twice a day, say at the 8 A. M. and the 5 p. m. 
meals. 

At fifteen months a child's diet should be as follows: 



406 DISEASES OF CHILDREN FOR NURSES 

8 A. M., 8 oz. of milk, 6 oz. of gruel, 
lo A. M., 8 oz. of milk. 

I P. M., 8 oz. of milk, a soft boiled egg, \ oz, orange juice. 
5 p. M., 8 oz. of milk, 6 oz. of gruel. 

9 P. M., 8 oz. of milk. 



A child should not have potatoes until it is eighteen 
months old. Rice in small quantities may be given at 
intervals after fifteen months. 

At eighteen months clear chicken or mutton soups 
may be added to the mid -day meal; also dried bread and 
a little butter. The other meals should be the same as 
at fifteen months. Do not give beef juice except when 
the child is in poor health, at which time it acts as a tonic. 
It will do no harm, but, on the other hand, it will do no 
good in health. 

At twenty-one months a child can digest meat in 
small amounts. '^Scraped beef from the inside of rare 
steak is the best, a tablespoonful of this may be added to 
the mid-day meal. 

The diet at twenty-one months will be as follows: . 

8 A. M., 8 oz. of milk, 6 oz. of gruel, soft boiled egg, bread and 
butter. 

ID A. M., 8 oz. of milk. 
I P. M., 6 oz. of clear soup, \ oz. of scraped beef, orange juice, 
bread and butter. 

5 p. M., 8 oz. of milk, 6 oz. of gruel, bread and butter. 

9 p. M., 8 oz. of milk. 

The milk is discontinued when the meat is given. 

Always give a child water between each meal; the best 
time is one hour before feeding. Let it have all it wishes. 

Milk should be pasteurized if scarlet fever is epidemic. 

At the beginning of the third year the 9 p. m. 
bottle of milk can be discontinued. At this age a child 
can go without food for twelve hours and it is a better 
plan to have it retire with an empty stomach. 



ARTIFICIAL FEEDING 407 

The orange juice should be continued ; vegetables 
may be added, but should always be put through a colan- 
der and served as a pulp. Potatoes, peas, squash, and 
spinach may be used. A dessert, such as junket, may be 
added. 

The diet during the third year will be as follows : 

8 A. M., orange juice, 10 oz. of milk, 6 oz. of gruel, soft boiled 
egg, bread and butter. 

10 A. M., 8 oz. of milk. 
I P. M., 6 oz. of soup, meat, vegetables, bread and butter, dessert. 
5.30 p. M., ID oz. of milk, 6 oz. of gruel, bread and butter. 

After three years of age three meals are sufficient. 
The food may be slowly increased in amount with a few 
additions until ten years of age. The diet will be as 
follows : 

Breakfast: Fruit, cereals, milk, bread and butter, one 
or two eggs. 

Dinner: Soup, meat, bread and butter, vegetables, and 
dessert. 

Supper: Cereals, milk, bread and butter. 

The foods which may be given during this period are 
milk, cream, eggs, rare beef, mutton, lamb, white meat of 
chicken, and well-cooked fish. 

Vegetables: Potatoes, asparagus tips, spinach, stewed 
celery, string beans, and fresh peas. 

Cereals : The best are the hominy grits, split wheat, and 
oatmeal. They should be cooked at least six hours. 
The prepared cereals should be cooked about four times 
as long as the directions say. 

Broths and soups. 

Bread and biscuits. 

Desserts: Junket, plain custards, rice pudding without 



408 DISEASES OF CHILDREN FOR NURSES 

raisins, and, not oftener than once a week, good ice 
cream. 

Fruits: Oranges, baked apples — ^never raw apples until 
ten years of age, and then with caution. Jams and 
preserved fruits cause trouble. 

Do not give fat or greasy food to children. Only the 
meats and vegetables mentioned are feasible. Also 
hot bread, griddle cakes, all nuts, candies, pies, tarts, 
salads, jellies, pastry of every description, tea, coffee, 
cocoa, beer, cider, bananas, and dried fruits should never 
be given to children. 

A light lunch at 10.30 or 11 o'clock spoils the appetite 
for dinner. It is better not to change the child's food 
during the hot weather. 

ADJUNCTS TO FEEDING 

The principal adjuncts to feeding during childhood are 
rest, exercise, and ventilation. 

Rest. — Young children about two years of age require 
a great deal of rest. They should sleep twelve hours at 
night, with a nap in the morning and one in the after- 
noon; the afternoon nap should be at least two hours in 
length. As the child becomes older the morning nap 
may be dropped. At ten years of age they should have 
at least from ten to eleven hours rest a day. 

Children should never be too active in the afternoon, 
as this is frequently the cause of bed-wetting. 

Exercise. — During the first year the baby gets enough 
exercise from waving its legs and arms about. During 
the second year a ''baby jumper" is helpful. From it 
the child obtains sufficient exercise without hurting and 
unduly tiring itself. If the child walks from room to 



ARTIFICIAL FEEDING 409 

room or about the chairs it should rest often to preserve 
the arch of the foot. Boys usually obtain sufficient 
exercise from their play. Exercise is the best cure for 
constipation. 

Ventilation. — Give children all the fresh air they can 
get, do not have their clothing too tight, and have a 
window open in the room at night. 

An infant requires 1000 cubic feet of fresh air. Older 
children should have between 700 and 800 cubic feet. 



CHAPTER XIX 

THERAPEUTICS 

In the treatment of children more can be accomplished 
by good hygienic surroundings, careful feeding, and 
proper nursing than by the administration of drugs. 
Drugs are necessary under certain conditions, when it is 
better to give divided doses frequently than a large amount 
at one time. 

Drugs well borne by children include alcoholic 
stimulants, which should be diluted eight times before 
administration, quinin, calomel, iodids, cod-liver oil, 
bromids, chloral, and belladonna. 

Belladonna often causes an erythema or redness of 
the skin even when given in small quantities, but this 
does not necessarily mean that the drug is producing 
deleterious effects. 

Chloral should be given by the rectum. When given 
by the mouth it causes irritation of the mucous mem- 
branes. 

Drugs poorly borne by children include opium, 
usually given in the form of Dover's powder, salicylates, 
iron, and acids. Children are more susceptible to opium 
than adults. The other drugs mentioned have a tendency 
to derange the digestion. Mixtures containing arsenic 
should be diluted with at least eight parts of water when 
administered. 
410 



THERA PE UTICS 4 1 1 

RULES FOR DOSAGE IN CHILDHOOD 

Several rules for dosage in childhood have been devised, 
founded on the fact that drugs influence the human organ- 
ism somewhat in proportion to the body weight. 

Young's Rule. — Add twelve to the age of the child 
and divide the sum into the age. This gives the pro- 
portionate quantity of an adult dose. Thus, the age of a 
child being two years, two plus twelve would be fourteen, 
and fourteen divided into two would be ^^ or \ of the 
adult dose, being the proper dose for a child of two 
years. 

Crowling's Rule. — Divide the age of the child at the 
following birthday by twenty-four, and the result is the 
proportionate dose for that child. Thus, the following 
birthday of a child being four years, /^ or \ of the adult 
dose would be the proper quantity for a child at three 
years. 

THE THERAPEUTIC LIMIT 

The therapeutic limit of a drug is the furthest point 
to which a drug can be pushed, with safety, in the treat- 
ment of a disease. 

The therapeutic limit of the following drugs is : 

Aconite. Tingling of the mucous membrane of the 
mouth and lips and a weak, compressible pulse. 

Antipyrin. Cyanosis, languor, and a weak pulse. 

Arsenic. Nausea and diarrhea. Puffiness under the 
eyes. 

Aspirin. Ringing in the ears. 

Belladonna. Dilation of the pupil, dryness of the 
mouth, and a rapid, corded pulse. 

Bromids. Mental torpor and an acne rash (bromism). 



412 DISEASES OF CHILDREN FOR NURSES 

Carbolic acid. Smoky urine. 

Cimicifuga. Frontal headache. 

Colchicum. Serous diarrhea. 

DigitaUs. A slow, full pulse. 

lodids. Headache, coryza, and sore throat. 

Mercury. Salivation, sore gums, and fetid breath 
(ptyalism). 

Oil of Wintergreen. Ringing in the ears. 

Opium. Contraction of the pupils and sleep. 

Phosphorus. Matchy taste. • 

Quinin. Ringing in the ears. 

Salicylates. Ringing in the ears. 

Salol. Ringing in the ears. 

Strychnin. Stiffness of the muscles of the neck, twitch- 
ing of the muscles, and nervousness. 

Sulphonal. Pinkish urine. 

Tartar Emetic. Nausea and a slow pulse. 

Thyroid Extract. Loss of weight and strength, fever, 
and a rapid pulse. 

CONTRA-INDICATIONS 

Aconite. Contra-indicated in weak heart. 

Alcohol. Contra-indicated in typhoid if odor is present 
on breath. 

Chloral. Contra-indicated in hypertrophied heart and 
disease of heart muscle. 

Chloroform. Contra-indicated in heart disease. 

Digitalis. Contra-indicated in hypertrophied heart and 
disease of heart muscle. 

Ether. Contra-indicated in disease of the bronchi and 
lungs. 

Hyoscin. Contra-indicated in sore throat. 



THE RAPE UTICS 4 1 3 

lodid. Contra-indicated in cavity formation in phthisis. 

Mercury. Contra-indicated in inflammations of a 
serous membrane with serous exudate. 

Nitrous Oxid Gas. Contra-indicated in aneurysm and 
arteriosclerosis. 

Opium. Contra-indicated in Bright's disease. 

Quinin. Contra-indicated in middle-ear disease. 

Strychnin. Contra-indicated in inflammations of the 
spinal cord. 

Tartar Emetic. Contra-indicated in infancy. 

Thyroid Extract. Contra-indicated in exophthalmic 
goiter. 

Tonics (Bitter). Contra-indicated in inflammations of 
gastro-intestinal tract. 

Veratrum Viride. Contra-indicated in gastric inflam- 
mations and weak heart. 

DOMINANT ACTION OF DRUGS 

Aconite depresses the heart directly. 

Amyl nitrite depresses the motor portion of the spinal 
cord. 

Bromids depress the motor portion of the spinal cord. 

Chloral depresses the motor portion of the spinal 
cord. 

Digitalis stimulates every portion of the circulation. 

Strychnin stimulates the motor portion of the spinal cord. 

DRUGS WHICH QUICKEN THE PULSE 

Alcohol. Ammonia. 

Atropin. Ether. 

Nitroglycerin. 



414 DISEASES OF CHILDREN FOR NURSES 

DRUGS WHICH SLOW THE PULSE 

Aconite. Digitalis. 

Chloroform. Opium. 

Veratrum Viride. 

DRUGS WHICH RAISE BLOOD PRESSURE 

AlcohoL Cocain. 

Ammonia. Digitalis. 

Atropin. Ergot. 
Strychnin. 

CHARACTERISTIC PULSES 

Aconite. Slow, weak pulse. 
Amyl Nitrite. Rapid, soft pulse. 
Digitalis. Slow, full pulse. 
Opium. Slow, full pulse. 
Veratrum Viride. Slow, weak pulse. 

DRUGS WHICH DILATE THE PUPIL 

Belladonna. Cocain. 

DRUGS WHICH CONTRACT THE PUPIL 

Eserin. Opium. 

DRUGS WHICH CAUSE SKIN REACTIONS 

Erythematous Eruptions : 

Antipyrin. 

Belladonna (resembles scarlet fever). 

Chloral. 

Quinin. 



THERA PE UTICS 4 1 5 

Acneiform Eruption : 

Arsenic. Bromids. lodids. 

Drugs causing Cyanosis : 

Antipyrin. Potassium chlorate. 

Hydrocyanic acid. Nitrites. 

DRUGS WHICH COLOR THE URINE 

Carbolic acid. Smoky urine. 
Creosote. Olive-green urine. 

Methylene -blue. Blue-green urine. 
Resorcin. Olive-green urine. 

Salicylates. Olive -green urine. 

Santonin. Yellow urine. 

Sulphonal. Pinkish urine. 

Thymol. Olive-green urine. 

Turpentine and eucalyptus give an odor of violets to 
urine. 

DRUGS WHICH COLOR THE STOOLS 



Bismuth. 


Black stool. 


Hematoxylin. 


Red stool. 


Iron. 


Black stool. 


Silver. 


Black stool. 



VACCINES 

These are dead bacteria suspended in normal salt 
solution and are used in the treatment of a large variety 
of conditions. 

In children the best results are obtained in cases of 
furunculosis and multiple abscesses. In most of the other 
conditions they have not been very successful, though 
occasionally cases may show marked improvement. 



4i6 



DISEASES OF CHILDREN FOR NURSES 



DRUGS QF THE U. S. PHARMACOPEIA MOST COMMONLY 
EMPLOYED IN CHILDREN'S DISEASES, TOGETHER 
WITH THEIR DOSES FOR CHILDREN TWO YEARS 
OLD 



Acetanilid, gr. ss-j. 

Aceta. 

Acetum opii, Tt^ss-j. 
scillae, Ttti-v. 

Acida. 

Acidum aceticum dil., 1fl\v-xv. 
carbolicum, gr. \. 
gallicum, gr. ss-ij. 
hydrocyanicum dil., Hfti-i- 
hydrochloricum dil., TTti-v. 
nitricum dil., TtXi-iij. 
nitrohydrochloricum diLjlTti-v. 
phosphoricum dil., IflXi-v. 
salicylicum, gr. j. 
sulphuricum dil., TTti-v. 

aromaticum, "TTti-Vo 
tannicum, gr. ss-ij. 

^therea. 

^ther, ntii-x. 
Chloroformum, 1T|^i-v. 

Ammonia. 

Ammonii bromidum, gr. i-v. 
carbonas, gr. ss-j, 
chloridum, gr. i-v. 

Antimonium. 

Antimonii et potassii tartras, gr. 

Antipyrin, gr. ss-ij. 
Aspirin, gr. ss-iss. 

Aquae. 

Aqua ammoniae. (External.) 
camphorae, f^j. 
cinnamomi, f^i^ij- 
menthae piperitae, i^^-^- 
rosae. (External.) 

Argentnm. 

Argenti nitras, gr. -^-^-jj' 
nitras fusa. (External), 
A tropin Sulph., gr. jh-^h- 



Bismuthum. 

Bismuthi subcarbonas, gr. i-v. 
subnitras, gr. i-v. 

Calcium. 

Greta praeparata, gr. ii-x. 
Testa praeparata, gr. ii-x. 

Carbo Ligni, gr. i-v. 

Cerata. (ExternaL) 

Ceratum canthar. 
cetacei. 
ext. canth. 
plumbi sub. 
resinae. 
resinae com. 
sabinae. 
saponis. 
zinci carbon. 

Chartae. (External.) 
Charta sinapis. 



Chloral, gr. i-v. 
Codein, gr. ^. 



1 

8 2¥' 



Collodium. (External.) 

Collodium cum cantharidfe. 
flexile. 

Confectiones. 

Confectio sennae, gr. x-xx. 

Decocta. 

Decoctum haematoxyli, i^i-i]- 
hordei, f^i-iv. 
quercus. (External.) 

Digitalin, n^ss-v. 

Emplastra. (External.) 

Emploastrum assafcetidae. 
belladonnae. 
hydrargyri. 
opii. 



THE RAPE UTICS 



417 



Emplastra. (External.) 

Emploastrum picis burgundicae. 
cum cantharide. 
resinae. 
saponis. 



Extracta. 

Extractum belladonnae, gr. -g^-xV- 
cinchonae, gr. i-iv. 
colocynthidis C, gr. \-\. 
gentianae, gr. \-'y 
glycyrrhizae, gr. i-v. 
haematoxyli, gr. i-iv. 
hyoscyami, gr. f_-i. 
krameriae, gr. \-\\. 
malti, Ttlxv-f^ss. 
nucis vomicae, gr. ^x"%i' 
taraxaci, gr. ii-x. 

Extracta Fluida. 

Extractum buchu fluid., TTLii-v. 
cascara sagrada fld., TTLii^x. 
cimicifugae fluid., tttiv-viij. 
ergotae fluid., TTLi-ij- 
gelsemii fluid., Tlli-i. 
grindeliae fluid., (External.) 
pilocarpi fluid., Tl\x. 
pruni virg. fluid., TTtx. 
rhei fluid., TTLi-v. 
sennae fluid., Tl^x-xxx. 
spigeliae et sen. fluid., f^j. 
uvae ursi fluid., Ttlii-v. 
Valerianae fluid., iTtii-x, 

Ferruin. 

Ferri citras, gr. ss-ij. 

et ammonii citras, gr. ss-ij. 

et potassii tartras, gr. ss-ij. 

et quininae citras, gr. ss-ij. 

lactas, gr. ss-ij. 

pyrophosphas, gr. ^-j. 

subcarbonas, gr. i-ij. 

sulphas exsiccata, gr. \-\. 
Ferrum reductum, gr. ss-ij. 

Glycerita, ^External.) 

Glycerinum acidi carbolici. 
gallici. 
tannici. 



Heroin, gr. 5I 



1 

8 2?* 



Hydrargyrum. 

Hydrargyri chloridum corros., 

mite, gr. ^^^iss. 
Hydrargyrum cum creta, gr. ss-iss. 

Infusa. 

Infusum buchu, f^i-ij. 
calumbas, f^i-ij. 
digitalis, Tttx-f^ss. 
lini, f^ss-ij. 

Kamala, gr. v-xv. 

Linimerita. (External.) 

Linimentum ammoniac, 
calcis. 
camphorae. 
cantharidis. 
chloroformi. 
plumbi subacetatis. 
saponis. 
terebinthinae. 

Liquores. 

Liquor acidi arseniosi, ITI^i-iij. 
ammonii acetatis, f^ss-j. 
arsenici et hydrarg. iodidi, 

mss-j. 

calcis, f.^i-f^^iij. 

ferri nitratis, 1TLi-iij- 
subsulphatis, TTLss-j. 

magnesii citratis, f^ii-f^ss. 

pepsini, f^^ss-f^j. 

plumbi subacetat. dil. (Ex- 
ternal.) 

potassii arsenitis, TTti-iij. 
citratis, f^ss-j. 

sodae chloratae. (External.) 

Magnesium. 

Magnesia, gr. v-gr. xl. 
Magnesii carbonas, gr. v-gr. xL 
sulphas, gr. v-xv. 

Manna, gr. xx-^j. 

Mellita. (External.) 
Mel despumatum. 
rosae. 
boracis. 



27 



4i8 



DISEASES OF CHILDREN FOR NURSES 



Misturse. 

Mistura ammoniaci, f^ss-ij. 
amygdalae, f^i-^fj. 
assafoetidae, f^i^ij- 
chloroformi, f^i-ij. 
cretas, f.^^ss-j. 
ferri comp., f^i-ij. 
ferri et ammonii acetatis, f,^ 

ss-j. 
glycyrrhizae comp., TTLxv-f^ss. 
potassii citratis, f^ss-j. 
rhei et sodae, f^ss-j. 

Morphina. 

Morphinae acetas, gr. j— To* 
murias, gr. -/g-gV. 
sulphas, gr. ^V-io- 

Moschus, gr. i-ij. 

Mucilagines. 

Mucilago acaciae, ad lib. 
sassafras medullae, ad lib. 
tragacanthae, ad lib. 
ulmi, ad lib. 

Nitroglycerin, gr. ^\-^. 

Olea. 

Oleum chenopodii, ITtii-iv. 
cinnamomi, HXi- 
gaultheriae, TJli-ij. 
menthas piperitae, TTLss-j. 
morrhuae, TTLxv-f^j. 
olivae, f^i-ij. 
ricini, f^ss-ij. 
succini. (External.) 
terebinthinas, 1TLii-v. 

Oleoresinae. 

Oleoresina aspidii, TTLv-xx, 

Opium, gr. ^Vi 
Pelletierine tannas, gr. i-v. 

Pepo, 5i-ij. 

Petrolatum (External). 
Phenacetin, gr. ss-j. 

Phosphorus, gr. eVrk- 

Plumbum. 

Plumbi acetas, gr. \-\. 



Potassium. 

Potassii acetas, gr. ii-v. 
bicarbonas, gr. ii-v. 
bitartras, gr. x-xv. 
"bromidum, gr. ii-v. 
chloras, gr. ii-v. 
citras, gr. ii-v. 
et sodii tartras, gr. xv-^j. 
iodidum, gr. ss-iij. 
nitras, gr. iss-viij. 
permanganas. (External.) 

Pulveres. 

Pulvis aromaticus, gr. i-ij. 
glycyrrhizae comp., gr. iv-viij. 
ipecacuanhae et opii, gr. ^-iss. 
rhei comp., gr. v-x. 

Quinina. 

Quininae bisulphas, gr. ss-iv. 
sulphas, gr. ss-iv. 
valerianas, gr. ^-ss. 

Resinae. 

Resina jalapae, gr. |-ss. 
podophylli, gr. -^-^j. 
scammonii, gr. ^-iss. 

Rheum, gr. ss.-ij. 
Salol, gr. ss-iss. 

Santoninum, gr. |-ss. 

Scammonium, gr. i-ij. 

Senna, gr. iii-v. 

Sinapis (Emetic), gr. viii-xx. 

Sodium. 

Sodii acetas, gr. ii-v. 
arsenias, gr. yiiryeV- 
bicarbonas, gr. ii-v. 
boras. (External.) 
bromidi, gr. i-v. 
salicylici, gr. ss-iss. 

Spiritus. 

Spiritus aetheris comp., TTtii-x. 
nitrosi, KtXv-xx. 
ammoniae aromat., 1Ttii~v. 
camphor ae, Tt], ss-iv. 
chloroformi, 1TLi-v. 



THERAPEUTICS 



419 



Spiritus. 

cinnamomi, TTLi-ij- 
frumenti, T11v-f,^j. 
juniperi comp., TTLv-xv. 
menthae piperitas, TTLss-ij. 
vini gallici, TTLv-f3J. 



Strychnina. 

Strychninae sulphas, gr. 



1 _ 1 
170 To7* 



Sulfonal, gr. iss. 
Sulphur. 

Sulphur praecipitatum, gr. x -xv. 

Syrupi. 

Syrupus acaciae, ad l^b. 
allii, f^ss-^ij. 
ferri iodidi, TTLii-v. 
- ipecacuanhae, TTtii-f^j- 
krameriag, TTLxx-f^j. 
lactucarii, "Hlxx-f^j. 
limonis, ad lib. 
pruni virginianae, TT^xv-f^ss. 
rhei, f^ss-j. 

aromat., f^ss-j. 
sarsaparillae comp., Kttxv-fgss. 
scillae, 1Ttii~vj. 

comp., TTLii-vj. 
senegae, TTLii-v. 
tolutani, TTLii-vj. 
zingiber is, ITtv-x. 

Tincturae. 

Tinctura aconiti, TTti-ss. 
belladonnae, TTLi-ij. 
calumbae, tlTiii-xv. 
cannabis indicae, TTti-ij. 
cardamomi comp., TTtv-xv. 
catechu comp., TTLv-xv. 
cinchonae comp., Ttlx-xv. 
cinnamomi, Tllii-xv. 
colchici, Tr[i-iij- 
digitalis, Tllss-iij. 
ferri chloridi, TlTi-v. 
gelsemii, TTti-ij. 
gentianae comp., TTtv-xv. 
guaiaci ammon, TTLv-xv. 
hyoscyami, TTLi-iv. 
iodi, TT[i-iv. 
ipecac, et opii, ITLi-iss. 
kino, tTLii-xx. 
krameriae, TT^ii-xx. 
lavendulae comp., TTLv-xXo 



Tincturae. 

nucis vomicae, TTtss-ij. 
opii, Tlli-iij. 

camphorata, tttv-xx. 

deodorata, TT^i-iij. 
rhei dulcis, TT^v-x. 
saponis viridis. (External.] 
scillae, 1TLi-v. 
strophanthus, TTtss-j. 
Valerianae ammoniata, IT^v-xv. 
zingiberis, TTtii-vij. 

Trional, gr. iss. 

Unguenta. (External.) 

Unguentum acidi carbolici. 
acidi tannici. 
aquae rosae. 
belladonnae. 
cantharidis. 
creasoti. 
diachylon, 
gallae. 
hydrargyri. 

ammoniati. 

iodidi rubri. 

nitratis. 

oxidi flavi. 
rubri. 
iodi ichthyol. 
mezerei. 
picis liquidae. 
plumbi carbonatis. 

iodidi. 
potassii iodidi. 
stramonii. 
sulphuris. 

iodidi. 
veratrinae. 
zinci oxidi. 

Veronal, gr. iss. 

Vina. 

Vinum ergotae, TTtv-x. 
ferri amarum, TTLxx-f^ss. 
ipecacuanhae, TTtii-viij. 
opii, 1TLss-j. 
rhei, TTLv-f^ss. 

Zincum. 

Zinci oxidum, gr. |-ss. 
sulphas, gr. |-v. 
valerianas, gr. J-ss. 

Zingiber. 

Pulv. zingiberis, gr. \-\\. 



420 



DISEASES OF CHILDREN FOR NURSES 



Normal Salt Solution. — One and one-half drams of 
sodium chlorid (ordinary table salt) are added to two 
piQts of sterile water, thoroughly mixed with a sterile 
glass rod, and filtered into a sterile bottle. 

If normal salt solution is to be used for hypodermoclysis 
it should be sterilized for a half hour on three successive 
days. In emergencies it may be boiled steadily for one 
hour. A sterile thermometer should be used to take the 
temperature of the solution. 



POISONS AND THEIR ANTIDOTES 



Acids, Mineral. — Alkalies in di- 
lute solution; lime; whitewash; 
magnesia; soap. Quickness of 
administration essential. Avoid 
emetics and stomach-pump. 

Acids, Vegetable. — Soap; soda or 
potassa in dilute solution; except 
for oxalic acid, for which give 
lime, whitewash, chalk, or mag- 
nesia. 

Aconite. — Emetics; stomach- 

pump; tannic acid; digitalis; 
laudanum; warmth; stimulation; 
recumbent position. 

Alkalies and Their Salts. — Vine- 
gar; weak acids; oil freely; opium. 

Alum. — Albumen.* 

Antimony and Its Salts. — Tannic 
acid; opium; external warmth. 

Arsenic and Its Salts. — Emetics; 
stomach-pump; recently made 
hydrated sesqui-oxid of iron; 
(made by adding water of ammo- 
nia to solution of trisulphate of 
iron); magnesia; dialyzed iron 
and salt; oil or fat. 



Atropin.— See Belladonna. 

Belladonna. — Emetics; stomach- 
pump; tannic acid; morphin 
hypodermically. 

Bismuth and Its Compounds. — 

Albumen; milk. 

Bromin. — Soap; oils. 

Cannabis Indica. — Emetics; lem- 
on juice; quiet; if exhaustion, 
stimulants. 

Carbolic Acid. — Stomach-pump; 
solution of saccharate of lime; 
sulphate of sodium; hot and cold 
douche. 

Chloral and Chloroform. — Alter- 
nate hot and cold douche; artifi- 
cial respiration; cardiac stimu- 
lants. 

Cocculus Indicus. — E m e t i c s ; 

stomach-pump; at first, give 
opium; chloral; chloroform; later, 
stimulants. No chemical anti- 
dote. 



* Albumen is furnished by whites of eggs. 



THERAPEUTICS 



421 



Colchicum. — Emetics; stomach- 
pump; tannic acid; opium; stim- 
ulants. 

Conium. — Emetics; stomach- 
pump; artificial respiration; tan- 
nic acid; opium. 

Copper and Its Salts. — Albumen; 
milk; calcined magnesia; yellow 
prussiate of potash. 

Croton Oil and Other Drastic 
Purgatives. — Emetics; albumi- 
nous drinks; bismuth; external 
heat. 

Cyanid of Potassium. — See Hy- 
drocyanic Acid. 

Digitalis. — Emetics; stomach- 

pump; tannic acid; stimulants. 

Gelsemium. — Same as Aconite. 

Hydrocyanic Acid. — Alternate hot 
and cold douche; intravenous 
injection of aqua ammoniac; 
atropin hypodermically. 

Hyoscyamus. — Same as Bella- 
donna. 

lodin. — Starch, freely; if this can- 
not be obtained, then soap. 

Iron, Salts of. — Soap; dilute 
alkalies; albumen. 

Lead, Salts of. — Emetics; stomach- 
. pump; alkaline sulphates; soap; 
albumen; milk; purge. 



Mercury, Saks of (Bichlorid of 
Mercury). — Emetics; albumen; 
milk; wash out stomach 

Opium. — Stomach-pump; atropin 
hypodermically; coffee; flagella- 
tion; artificial respiration; elec- 
tricity. 

Phosphorus.— Emetics; sulphate 
of copper in small doses; crude 
oil of turpentine; stomach-pump; 
avoid oils or fats. 

Potash Salts.— No distinct anti- 
dote. 

Santonin.— Emetics; purges; stim- 
ulants; artificial respiration. 

Silver, Salts of.— Common salt, 
freely; albumen. 

Soda Salts.— No distinct antidote. 

Stramonium.— Same as Belladon- 
na. 

Strychnin.— Emetics; stomach- 
pump {at iirst only) tannic acid; 
chloral; bromid of potash; ether; 
chloroform; rest. 

Veratrum Viride.— Same as Aco- 
nite. 

Zinc, Salts of .—Albumen in the 
form of white of egg; carbonate 
of soda; milk, freely. 



422 DISEASES OF CHILDREN FOR NURSES 

TREATMENT OF EMERGENCIES 

The following treatments are given so that the nurse 
may know what to do in cases of extreme emergency, where 
it is impossible to obtain a physician immediately and 
where delay might result in the death of the child. 

In every emergency case send for the physician at once, 
and while awaiting his arrival do as much for the patient 
as can be done without exercising his prerogatives, and 
at the same time have everything prepared so that his 
orders may be anticipated and the patient receive immedi- 
ate medication. When the nurse knows what orders to 
expect, the detail can be worked out before the physician 
arrives. 

Asphyxia. — Give artificial respiration (see page 454). 
Oxygen, atropin, 4^0 gr., and strychnin, go gr., hypo- 
dermically, to a child four years of age, will probably be 
ordered. 

Asthma. — Prompt relief often follows the inhalation of 
a few drops of chloroform. 

Bites should be treated as open wounds and not cau- 
terized. They should be thoroughly washed with hydro- 
gen peroxid and a wet bichlorid dressing applied. 

Burns. — The burned area should be covered with lint 
saturated with normal salt solution or carron oil, which is 
composed of equal parts of linseed oil and lime-water. 

Chills. — The child should be surrounded with hot- 
water bottles and covered with a blanket. Hot drinks 
may be administered. If this plan of treatment is fol- 
lowed by a sweat, the skin should be sponged with water 
containing a tablespoonful of alcohol to the basin. The 
temperature should be taken. 



THE RAPE UTICS 423 

Collapse. — Place the child in a mustard tub at a 
temperature of 110° F. for five minutes, vigorously rubbing 
the extremities and the skin surfaces during this time. 
After removal from the tub place it in a horizontal posi- 
tion, cover with warm blankets; heart and respiratory 
stimulants will probably be ordered. 

Croup. — ^A sponge moistened with hot water may be 
applied to the throat, or the child may be placed in a hot 
bath or mustard tub at a temperature of 110° F. If these 
simple remedies fail, an emetic will often bring relief, 
the best being the wine of ipecac administered in dram 
doses until effective ; or a little powdered alum mixed with 
honey or molasses given in teaspoonful doses. In severe 
cases it may be necessary to resort to the inhalation of a few 
drops of chloroform. A croup tent with moist atmosphere 
is advantageous. An umbrella covered with a blanket 
may be substituted for the regulation croup tent. 

Convulsions. — Epileptiform. — Measures should be 
taken to prevent the child from injuring itself. Some- 
thing should be placed between the teeth to prevent 
biting of the tongue. An enema should be given. 

Uremic. — The same precautions must be taken as in 
epileptiform convulsions. The inhalation of a few drops 
of chloroform may control the seizures until the physician 
arrives. 

Reflex Convulsions. — The child should be placed in 
a mustard tub, at 110° F., for five minutes. . 

Dislocations. — Apply cold to the joint. 

Drowning. — The child sljould be forced to vomit to 
relieve the stomach of the swallowed water; this can be 
accomplished by pressure over the stomach. Artificial 
respiration should then be practised (see page 454)- 



424 DISEASES OF CHILDREN FOR NURSES 

Dyspnea. — Dyspnea may be due to a number of causes. 
If the child is suffering from heart disease, it should be 
propped up in bed. If due to some disease of the respira- 
tory tract, a croup tent with a moist atmosphere may help; 
oxygen should be administered if at hand, or the child 
should be kept in a room filled with fresh air or even 
carried out of doors. If due to diphtheria, intubation 
will probably be necessary. Heart or respiratory stimu- 
lants will probably be ordered. 

Epistaxis or Nosebleed. — The child should sit upright 
in the chair, the clothing should be loosened about the 
neck, firm pressure made over the bridge of the nose by 
holding it between the fingers, and ice should be applied 
to the bridge of the nose and back of the neck. Small 
pellets of ice may be introduced into the nostrils or held 
in the mouth. If this does not answer, plugging the 
nostrils with absorbent cotton may be resorted to. Com- 
pound tincture of benzoin, diluted lemon-juice, and adre- 
nalin chlorid, i : 2000, may be introduced into the nose. 
No astringent powders should be used locally on account of 
their tendency to produce sneezing, thus starting the nose- 
bleed afresh. 

Earache. — Douche the ear with warm water at a tem- 
perature of 110° F. for about five minutes (see page 443). 
Then introduce a pledget of cotton saturated with sweet 
oil and a drop of laudanum. 

Fainting. — Loosen the clothing; place the child on its 
back with the head on a lower level than the feet; use 
smelling salts and aromatic spirits of ammonia, ten drops 
in a tablespoonful of water for a child four years of age. 

Foreign Bodies. — Eye. — If possible remove the body 
with a wisp of cotton; if it cannot be discovered turn the 



THERAPEUTICS 425 

Kd as described on page 252, when, in most cases, it can 
readily be found. 

Ear. — Nothing should be used except hot-water douch- 
ings; on no account attempt to probe with any instrument; 
the douching will be sufficient for all cases. 

Nose. — Douching the nose with warm water is usually 
sufficient, the nozzle of the syringe being placed in the 
nostril which is free. 

Throat. — Often a sharp slap on the back will cause the 
expulsion of the foreign body. If it is impossible to 
recover the object and it seems to be lodged in the throat, 
send immediately for the physician. If it has been swal- 
lowed give the child bread and potatoes to eat, and a 
dose of oil. 

Fractures. — If simple, apply a temporary dressing and 
splint to avoid unnecessary laceration of the tissues. 

If compound (communicating with the air) wash thor- 
oughly with a solution of bichlorid of mercury, i to 4000, 
and apply a wet bichlorid or normal salt solution dressing. 
In fractures of skull, apply an ice-cap. 

Heart Failure. — Symptoms of heart failure demand 
instant attention. Whenever the pulse becomes rapid, 
intermittent, and weak, or the child- has sudden attacks of 
dyspnea, coldness of the extremities, or attacks of syncope, 
the physician should be immediately informed. While 
awaiting his arrival the child should be placed flat upon 
its back and not moved for anything. Mustard paste, 
made of equal parts of mustard and flour, may be ap- 
plied to front of chest until there is a distinct redness, 15 
minims of aromatic spirits of ammonia may be given in 
water by the mouth, if the child can swallow; hot-water 
bags may be placed about the extremities, and inhala- 



426 DISEASES OF CHILDREN FOR NURSES 

tions of ammonia given. (Be careful not to have con- 
centrated ammonia nor to hold it continuously under the 
nose; pass it slowly backward and forward.) The phys- 
ician will probably order a hypodermic injection of one of 
the following drugs: nitroglycerin, strychnin, digitalis, or 
whisky, all of which should be in readiness. Hypodermo- 
clysis may be ordered and at times he may bleed the child. 

Hemorrhage. — Hemoptysis (Spitting of Blood). — Mor- 
phin should be administered in profuse hemorrhages, 
the dose being -3^2" gi"- to a child four years of age. Ice- 
bag to chest. 

Hematemesis (Vomiting of Blood). — An ice-bag should 
be placed over the stomach and all food by the mouth 
prohibited. If profuse, morphin, -3^2" g^., to a child of four 
years can be administered hypodermically. 

Typhoid. — The hemorrhage from the bowel should be 
treated by absolute rest, ice-bag to the abdomen, the 
food should be reduced to the minimum and of the mildest 
character. In severe cases the foot of the bed can be 
raised and morphin, dose -^-^ gr. to y^g- gr. to a child of 
four years, should be administered hypodermically. 

Laryngismus Stridulus. — Dash cold water on the 
face and neck in an attempt to break the spasm. Mustard 
tubs at a temperature of 110° F. may be resorted to, and 
in severe cases inhalations of chloroform. 

Nervousness. — Warm baths at a temperature of 
110° F. will usually allay nervousness. 

Pain can usually be relieved by the application of 
heat; that is, hot-water bag, turpentine stupe, etc. 

Perforation. — Typhoid. — Absolute quiet; no food or 
liquids by mouth or rectum. The physician should be 
immediately notified. 



THERAPEUTICS 427 

Appendicitis. — The same plan of treatment should be 
followed. 

Poisons. — If possible wash out the stomach, give a 
large dose of oil, and administer the proper antidote 
(see page 420). 

Prolapse of the Rectum. — The prolapsed portion of 
the bowel should be greased with vaselin, cold cloths 
applied, and gently pushed within the sphincter. 

Respiratory Failure. — In respiratory failure there is 
great dyspnea, cyanosis, and signs of collapse. The 
physician should be immediately summoned ; in the mean- 
time, if the child shows great distress in breathing while 
in the recumbent posture, it should be propped up in bed, 
oxygen should be administered; gentle friction of the sides 
of the chest at times stimulates the respiratory muscles. 
He may order a mustard tub and hypodermic injections 
of one or more of the following drugs: atropin, caffein, 
strychnin, and nitroglycerin. In sudden attacks of great 
cyanosis a mustard tub is advantageous. 

Shock. — Hot (iio°F.) normal salt solution or hot coffee 
may be injected into the rectum; about a pint should be 
used. Heart and vasomotor stimulants will be ordered; 
like strychnin, ammonia, and digitalis. 

Sunstroke. — The child's clothing should be removed 
and cool drinks administered. The child should be placed 
in the coolest part of the room, ice-bags applied to the 
head, and cool sponging given. At times it is necessary 
to give cold baths and cold irrigations of colon (see page 
429). Stimulation should be resorted to if necessary. 

Urine. — Suppression of the urine may be overcome by 
giving the child plenty of water to drink and administering 
sweet spirits of niter, dose ten drops in water every three 



428 DISEASES OF CHILDREN FOR NURSES 

hours to a child of two years, until the kidneys become 
active. 

Retention oj the urine at times may be overcome by a 
hot sitz bath or a warm tub. If this fails and the child 
is suffering, catheterization is necessary (see page 471). 

Persistent Vomiting. — Usually a mustard plaster 
applied for ten minutes over the stomach will relieve the 
vomiting. No food should be given by the mouth. 
Cracked ice will relieve the thirst. 

Wounds. — All wounds should be thoroughly cleansed 
(all the dirt removed, w^ashed with peroxid of hydrogen 
or a solution of bichlorid of mercury, i : 4000) and 
covered with a wet bichlorid or sterile normal salt solution 
dressing. 

Therapeutic Measures Employed in Childhood 
TO REDUCE TEMPERATURE 

Ice-cap. — Ice is placed in a canvas bag and beaten 
with a mallet until broken in small pieces. It is then 
transferred to a rubber ice-bag. Express all air from the 
bag by twisting the unfilled portion. Carefully apply 
metal cap ; then cover with towel or gauze. 

Sponge Bath. — The temperature of the water should 
be from 85° F. to 90° F. Equal parts of water and 
alcohol or water and vinegar can be used. The clothes 
should be removed from an infant with the exception 
of the diaper. In older children the portions of the body 
not being sponged may be kept covered. The sponging 
should be continued for five to fifteen minutes and the 
child then wrapped in a blanket without further dressing. 
The temperature of a child should be taken half an hour 
after sponging. 



THERAPEUTICS 429 

Cold Pack. — The child is stripped of all its clothing, 
laid upon a blanket, and the entire trunk wrapped in a 
sheet which has been wrung out of water at a temperature 
of 100° F., the sheet should be so apphed that one 
part of the body does not come in contact with another. 
Small pieces of ice are rubbed over the sheet, first in front 
and then behind. The head should be sponged with 
cold water and a hot-water bottle applied to the feet during 
this procedure. After the ice has been rubbed upon the 
sheet for ten minutes the child is enveloped in the blanket 
without removing the wet pack. The applications of ice 
should be made every fifteen or thirty minutes if ordered, 
and may be continued at these intervals for one or twenty- 
four hours. 

Graduated Cold Bath.^The child is placed in a tub 
of water at a temperature of 100° F. The temperature 
is then gradually reduced by the addition of ice wrapped 
in towels or by cold water until the temperature of the 
water is 85° F. or 80° F. While in the tub the child's 
body should be vigorously rubbed and an ice-bag or cold 
cloths should be applied to the head. The bath may 
be continued for ten or fifteen minutes. Upon removal 
the child's body should be quickly dried and wrapped in 
a warm blanket. The temperature of the child should 
be taken half an hour after removal from the bath. 

Cold Irrigation of the Colon. — Water of 40° F. to 
50° F. is injected through a catheter into the rectum. 
About a pint should be injected at one time. When 
introducing the catheter, if the end is placed immediately 
within the sphincter and then a small amount of water al- 
lowed to run, the rectum will dilate and permit the further 
introduction of the catheter to be accomplished easily. 



430 DISEASES OF CHILDREN FOR NURSES 

Measures to reduce temperature should be stopped if 
the child becomes very blue. 

COUNTER-IRRITATION 

Cantharides Blister. — The surface of the skin which 
is to be bhstered is thoroughly scrubbed and washed with 
alcohol. The cantharides plaster should be cut to the 
proper size and its surface oiled. It should then be 
applied and allowed to remain in position for six hours. 
The plaster should be removed carefully, and if the skin 
is raised cut the lowest portion of the bleb and allow the 
fluid to run out, carefully protecting the sound skin. Do 
not tear the blistered skin, as it causes a great deal of pain. 
Apply zinc-oxid ointment. If the blister is not raised at 
, the expiration of the six hours apply boric-acid ointment 
covered with a thick layer of cotton; this will cause it to 
raise in a few hours. 

Mustard Paste or Mustard Plaster. — Take one part 
of powdered mustard and six parts of wheat flour, mix 
with white of egg or lukewarm water, and spread between 
two layers of old linen or muslin. White of egg is used in 
preference to water, as it prevents blistering. 

In pulmonary diseases the mustard paste should sur- 
round the chest, and in heart failure it should cover the 
entire trunk. 

Mustard Poultice. — One part of mustard added to six 
parts of flaxseed and thoroughly mixed in lukewarm 
water. When ordered the strength can be increased up 
to one part of mustard to three parts of flaxseed. It is a 
very useful method of applying mustard over longer periods. 

Mustard Bath (Heubner's). — An extremely heroic 
mustard bath given in some cases of collapsed lung. 



THERAPEUTICS 43 1 

The proportions are one pound of mustard to one and a 
half quarts of water. A sheet is wrung out in the above 
and wrapped about the child from the axillae to the feet; it 
is allowed to remain in this dressing for from fifteen to thirty 
minutes. The mouth, nose, and eyes must be protected 
from the mustard fumes. After removing the sheet the 
child must be given a warm tub in order to thoroughly 
remove all traces of the mustard. The real object of this 
procedure is to get the child to cry vigorously from the 
irritation of the mustard, and in this way to expand the 
collapsed portion of the lung. (For Mustard Tub, see 
page 440.) 

Mustard Pack.— The child should be stripped and 
laid upon a blanket; the trunk should be surrounded 
with a sheet dipped in mustard water. This is prepared 
by adding one tablespoonful of mustard to a quart of 
tepid water. After the wet sheet is applied the child 
should be wrapped in a blanket. It should be removed 
in from ten to fifteen minutes. 

Turpentine Stupe. — A teaspoonful of turpentine is 
mixed with a pint of boiling water. A flannel cloth is 
dipped in this mixture and wrung out very tightly in a 
stupe wringer. It is then applied to the part affected 
and covered with oiled silk or wax paper. A thick layer 
of cotton should be placed over all, to retain the heat. 

Camphorated oil, amber oil, and olive oil, four parts, 
mixed with turpentine, one part, are liniments which may 
be applied to the chest. They are either rubbed in with 
the hand or applied by means of flannel cloths wet with 
the preparation. 

Dry Cups. — A small medicine glass is selected, the 
edges of which should be carefully oiled before using. 



432 DISEASES OF CHILDREN FOR NURSES 

One or two drops of alcohol are placed in the glass, it Is 
then manipulated so that the alcohol covers the sides of 
the vessel with a thin film, care being taken that no drops 
of the liquid are present. The alcohol is then lighted, 
and, while burning, the glass is inverted and the mouth is 
held firmly against the skin. The skin will be sucked 
up into the glass on account of the vacuum, and the cup 
will be firmly held in place. They are allowed to remain 
in position for fifteen or thirty minutes. To remove, 
press the skin down at one side of the glass in such a way 
that air is allowed to enter. The greatest care is necessary 
in the application of cups to prevent burning of the skin. 
This is caused by a drop of burning alcohol running down 
the sides of the glass and falling on the skin, or by over- 
heating the edges of the glass. 

Wet Cups. — The skin should be scrubbed. The phys- 
ician will then scarify the part to be cupped and apply 
the cups in the same way as described above. 

POULTICES 

Antiseptic Poultices. — Absorbent cotton wet with a 
solution of bichlorid of mercury, i to 4000; potassium 
permanganate, i to 4000; or carbolic solution, i to 40, and 
covered with green protective or wax paper. 

Charcoal poultice is used as a deodorizer. One part 
of powdered charcoal is added to two parts of linseed 
and prepared like a flaxseed poultice. Powdered charcoal 
is spread over the surface. 

Digitalis Poultice. — Make a flat bag and fill with 
leaves of digitalis. The bag should be steeped in boiling 
water and applied, or soak digitalis leaves, 2 oz. to a 
pint, in warm water, until they are soft, drain off the 



THERA PE UTICS 433 

water, and boil them. The decoction can then be added 
to flaxseed. 

Flaxseed Poultice. — According to the size of the 
poultice which is required, a quantity of flaxseed is added 
to boiling water until the mixture is thick enough to stir. 
It is then thoroughly beaten over a flame to fill the poultice 
with air J this makes the poultice light. A layer half 
an inch thick is spread over old linen, applied to the 
affected part, and covered with wax paper. In some 
conditions, such as pneumonia and peritonitis, the lightest 
possible poultices are necessary; layers less than half an 
inch are then applied. 

Spice Poultice. — Equal parts of allspice, cinnamon, 
ginger, and cloves are placed between two layers of flannel 
or gauze, which are then quilted. It is then wrung out 
of hot whiskey or brandy, applied to the part affected, and 
covered with wax paper. In heating whiskey or brandy 
they should never be placed upon the stove or near a 
flame. They should be poured into a cup which is then 
placed in a receptacle containing boiling water. 

Starch Poultice. — The starch is first mixed with a 
little cold water, and then enough boiling water is added 
to make a paste. It is spread on old linen or muslin, 
covered with a layer of gauze, and applied like other 
poultices. A few drops of laudanum may be sprinkled 
over the surface of the poultice before applying, if there is 
much pain. 

A preferable form of starch poultice for skiQ diseases 
is to make a flat bag and fill with dry potato starch; then 
dip in boiling water and allow to cool. 

Technic. — All poultices should be beaten until they 
are thoroughly filled with air; this renders them light in 
28 



434 DISEASES OF CHILDREN FOR NURSES 

weight. They should be covered with wax paper or oiled 
silk and a thick layer of cotton to keep them warm. News- 
papers may be used in emergencies. A margin of i inch 
of the linen should be left* to turn in, the surface of the 
poultice should be anointed with oil to protect the skin, 
and one poultice should not be removed until another is 
ready for application, the skin being wiped dry before the 
new one is put in place. Before applying a poultice, test 
its temperature by holding it to your face. Do not leave 
one poultice on over an hour. 

COMPRESSES 

Cold compresses are made by wringing cloths out of 
cold water and applying to the body. 

For the eyes small disks are cut from muslin or lint and 
placed upon a cake of ice. When they are thoroughly 
cold they are laid over the closed eyelids. They should 
be changed constantly. 

Hot compresses for the eyes are prepared in the same 

manner, boiling water being used instead of ice. The 

disk should be tested upon the back of the hand before 

application. 

HOT APPLICATIONS 

Hot-water bags are filled with water as hot as can be 
borne. All the air should be expressed before screwing 
on the top, and the bag should be placed in a properly 
flitting flannel cover to prevent burning of the skin. 

Hot Foot-baths. — The bed should be protected with 
a rubber mackintosh, which in turn is covered with a towel. 
A small foot-tub is placed upon this, containing enough 
water to cover the child's feet at a temperature of 1150 F. 
The exposed portions of the child's legs should be covered 



THERAPE UTICS 43 5 

with towels. After three minutes a quart of hotter water 
is added, care being taken not to allow it to come in contact 
with the child's extremities. The addition of hotter water 
is continued at these intervals until the water is as hot as 
can be borne by the hand. The child's feet should remain 
in the water at this temperature for about fifteen minutes, 
when they are quickly dried and wrapped in a warm 
blanket. 

Hot Bath. — The child is placed in a tub of water at a 
temperature of 100° F. The temperature is gradually 
raised to 110° F. by the addition of hot water. A ther- 
mometer should be used so that the temperature of the 
water is not raised too high. The body should be vigor- 
ously rubbed and an ice-cap or cold cloths should be applied 
to the head while the child is in the bath. The bath 
should last for ten to fifteen minutes. 

Hot Pack. — The clothes are removed and the child is 
wrapped in a blanket wrung out of water at a temperature 
of 110° F. The child should then be rolled in a second 
dry blanket covering the first. Hot-water bottles should 
surround the child and an ice-cap or cold cloths should 
be applied to the head. These hot applications can be 
applied every twenty or thirty minutes until free per- 
spiration is produced. Hot water or lemonade may be 
given to induce sweating; the sweat may be continued as 
long as desirable. At the expiration of the necessary 
time the moist blanket is removed, care being taken not to 
expose the child, a warm, dry blanket taking its place. 
The child is then sponged with warm water and alcohol 
to remove the perspiration. The undershirt and night- 
gown are then replaced and the ice-cap removed, the 
child always remaining between warm blankets. 



436 



DISEASES OF CHILDREN FOR NURSES 



Modified Hot Pack. — The child is wrapped in dry hot 
blankets. Hot-water bottles are placed under the arms, 
knees, and feet. An ice-cap over the head. Hot lemon- 
ade should be given and the pack terminate as above. 

Vapor Bath. — The bed should be covered with a mack- 
intosh and blanket. The clothing is removed and a 




Fig. io6. — Vapor bath. The covers are held above patient by means of a frame. 
They are tightly tucked in all around bed. The steam is introduced from kettle at foot 
of bed. An ice-cap is applied to head. Warm or cold beverages are administered to 
induce perspiration. 



blanket is placed loosely over the child. A frame reaching 
from the neck to well below the feet is placed over the 
patient. All metal parts of the frame must be covered 
by a bandage or old muslin to prevent condensation of the 



THERAPEUTICS 437 

steam. Over the frame, in the following order, are placed, 
first, a blanket, then a mackintosh with the rubber side 
toward the patient, completely covering the frame, and, 
finally, several blankets covering the whole apparatus. 
A thermometer should be placed on the chest of the child 
where it can be readily obtained. The covers are then 
tucked in securely at the top and both sides of the frame. 
If desired the blanket which loosely covers the child can 
now be withdrawn from the opening at the foot. This 
blanket is usually allowed to remain in giving vapor baths 
to children. The covers are then tucked in about the foot 
of frame, a small opening being left which should be of 
sufficient size to allow the introduction of the spout or 
hose leading from the steam kettle. 

Before applying the steam an ice-cap is placed on the 
child's head, boiling water is placed in the kettle, and the 
alcohol lamp beneath is lighted. When steam appears, 
the spout or hose is placed through the opening left for 
that purpose, care being taken not to place the spout over 
the child's feet, as the drip from its end is liable to scald 
the skin. 

The thermometer should be read every five minutes, 
care being exercised not to expose the chest. When the 
thermometer reads 120° F. the kettle should be removed 
and the child allowed to remain exactly as before for 
twenty or thirty minutes. If the thermometer at no time 
registers 120° F. the steam is kept up for thirty minutes. 

During the bath give hot or cold water freely; hot 
lemonade is also used at times to induce perspiration. 

At the end of twenty or thirty minutes after the ther- 
mometer has reached 120° F. the frame is carefully 



438 DISEASES OF CHILD I^ EN FOR NURSES 

removed from under its covering in such a way that there 
is no exposure nor disturbance of the covering, the steam 
thus being retained. The child remains in this position 
for twenty minutes. At the expiration of this time the 
moist blankets and mackintosh are carefully removed, 
warm, dry blankets taking their place. The child is then 
sponged with warm water and alcohol to remove the 
perspiration. The undershirt and night-gown may then 
be replaced and the ice-cap removed. The child should 
ahvays remain between warm, dry blankets. 

In private houses an attachment at tunes can be made 
to the steam-heat radiators; this saves a great deal of 
trouble in chronic cases. 

A tea ketde with a garden hose attached to its spout, 
the other end placed at the foot of the bed, will answer 
very well when no special apparatus is at hand. 

A piece of stove-pipe covered with asbestos can be fitted 
up to answer the same purpose. Holes should be punched 
through its sides for ventilation, and it should have an 
" elbow, " so that it can be directed over the foot of the bed. 
Inside of the stove-pipe, standing on a piece of asbestos^ 
place an alcohol lamp over which can be placed a tin cup 
filled with water. 

In the country or where it is impossible to generate 
steam by any of the above methods, hot bricks plunged into 
a basin half-filled with cold water may answer. 

Hot-air Bath. — The child and bed are prepared as in 
the vapor bath, only the steam is omitted. Hot air is 
introduced beneath the blanket by placing the alcohol 
lamp beneath the spout of an open kettle. This generates 
heat at this point, which passes into the bed. 



THERAPEUTICS 439 

The stove-pipe, as described above, can be used here, 
the cup of water being unnecessary. 

In many modern houses the electric light can be taken 
advantage of to give hot-air baths. A 30-candlepower 
electric bulb should be purchased. The child and bed 
can be prepared as in the vapor bath, except for an opening, 
which should be left over the upper portion of frame, 
through which the bulb can be passed and securely tied to 
the frame in such a way that there will be no danger of 
burning the child or the blankets. After the bulb is in 
place the opening can be closed. All the adjunct meas- 
ures as described under the vapor bath should be carried 
out. 

A sitting hot-air bath can be given by placing the child 
wrapped in a blanket on a chair, with his feet in hot 
water. Blankets draped from his shoulders should cover 
the child and the chair. Beneath the chair place an alco- 
hol lamp in a bucket, or the 30-candlepower lamp may be 
used. 

In any of the above baths, if pilocarpin has been ordered 
by the physician, it should be given at the time the nurse 
is about to begin the preparation for the bath. Then it 
will be fully active during the bath. 

Sitz Bath. — Useful when there is retention of urine, 
pain in pelvic region, or rectal congestion. A simple 
method is to place the child in the sitting posture in a tub 
of water at 115° to 120° F. The water should come to the 
level of the umbilicus. 

Salt Baths. — Prepared by adding from 3 to 5 oz. 
of sea salt to a gallon of water at a temperature of 
90° F. to 100° F., the number of gallons used in a 



440 DISEASES OE CHILDREN EOR NURSES 

bath varying. When the solution of salt is of sufficient 
strength the water causes the skin to glow. The baths 
are useful in rickets. 

Mustard Bath. — The bath is prepared by placing 
four or five tablespoonf uls of dry mustard in a gauze bag, 
which is shaken in four or five gallons of water until it is 
thoroughly saturated with the mustard. The water 
should be at a temperature of 105° F. when the child is 
put into the tub, after which it should be slowly raised to 
110° F. by the addition of hot water. An ice-cap or cold 
cloths should be applied to the head and the body vigor- 
ously rubbed while the child is in the tub. It may be 
continued for ten minutes, at the expiration of which time 
the child should be quickly removed and wrapped in a 
blanket without drying. 

Mustard Foot-bath. — At times it is impracticable to 
put children in a tub ; then a mustard foot-bath is useful. 
The bed is protected by a rubber blanket covered with 
towels. Cloths are wrung out of mustard water made by 
adding a teaspoonful of mustard to a quart of water and 
heated to 110° F. These are wrapped about the child's 
feet, the rest of the body being covered. They are applied 
until the skin becomes red. 

BATHS USED IN TREATING SKIN DISEASES 

Bran Baths. — Place one quart of ordinary wheat bran 
in a gauze bag and place in four or five gallons of water. 
The bag should be shaken and squeezed until the water 
resembles a thin porridge. The temperature should be 
maintained at 95° F. 

Alkaline Baths. — The quantity of water should be 



THERAPEUTICS 44 1 

twenty-two and a half gallons, at a temperature of 95 ° F. 
In this is placed : 

Carbonate of soda, 3 oz. 

Bicarbonate of soda, 3 oz. 

Carbonate of potassium, 3 oz. 

Borax, 3 oz. 

Compound Glycerin Bath. — Water, twenty-two and a 
half gallons, at a temperature of 95° F. Ingredients: 

Glycerin, 2 oz. 

Tragacanth, i oz. 

The bath must be used immediately, as this mixture 
forms glue. 

Compound Sulphur Bath. — Water, twenty-two and 
a half gallons, at a temperature of 95° F. Ingredients: 

Precipitated sulphur, i lb. 

Sodium hyposulphite, i oz. 

Acid sulphuric (strong), i dr. 

Water, i pt. 

To be mixed and then added to tub. 

Linseed Bath. — Add one pound of linseed to twenty- 
two and a half gallons of water at a temperature of 95 ° F. 

Starch Bath. — Take four tablespoonfuls of crushed 
starch and make a paste by adding cold water. Then 
add two quarts of boiling water, stirring over a fire until 
it makes an ordinary laundry starch. To twenty gallons 
of water at a temperature of 95° F. add 4 oz. of wash- 
ing soda and then add the cooked starch. 

If especially ordered, 4 oz. of glycerin and 4 oz. of borax 
may be added to the above, or the following: 

Sodium biborate, \ oz. 

Sodium carbonate, 2 oz. 

Potassium carbonate, 3 oz. 



442 DISEASES OF CHILDREN FOR NURSES 

Two to four teaspoonfuls of this mixture are added for 
every gallon of water, with double the amount of dry 
starch. 

Tar Bath. — The patient is rubbed with oil of cade on 
the diseased patches and then is given a warm bath or a 
plain starch bath. 

Vinegar-and- Mercury Baths. — Water, twenty-two 
and a half gallons, at a temperature of 95 ° F. Ingredients : 

Vinegar, i pt. 

Glycerin, i pt. 

Bichlorid of mercury, i dr. 

HYGIENIC BATHS 

Tepid Bath. — Given at a temperature of from 95° to 
100° F. It is useful in nervous conditions and to induce 
sleep. 

Shower Baths or Sponge Baths. — The child should 
stand in a foot-tub containing warm water. A large sponge 
holding about a pint of water at from 40° to 60° F. 
should be squeezed three or four times over the chest, 
shoulders, and spine of the child, the skin being vigorously 
rubbed meanwhile. The bath should not last more than 
half a minute, and should be followed by a brisk rubbing 
until a thorough reaction is established. 

SYRINGING 

Eye Syringing. — The lids should be massaged to 
remove pus, then held apart by the fingers, and any dis- 
charge dislodged from beneath them. A soft-rubber 
ear syringe is filled with saturated solution of boric acid 
heated to 100° F., and the nozzle is placed at the inner 
can thus of the eye. The solution should be wiped away 



THE RAPE UTICS 



443 



with antiseptic cotton. Always wipe toward the external 
canthus, to avoid contamination of the other eye. Medi- 
cine which is to remain in the eye is dropped in at the 
external canthus. The rubber ear syringe is safer to use 




Fig. 107. — Method of syringing eye. The cotton held against the nose should prevent 
any infection of other eye. 



than the ordinary glass eye-dropper, as children are prone 
to struggle. 

Ear Syringing. — An ear syringe is filled with water at a 
temperature of 110° F, The soft -rubber nozzle is placed 
within the external auditory canal and the bulb gently 
squeezed. A half pint to a quart of water is used. 

A fountain syringe held on a level with the ear can be 
substituted for the small syringe. The bag should be 
filled with a quart of water at 110° F., and a small nozzle 
held in the auditory canal. Do not raise bag above 
level of ear as it causes too great a pressure. 



444 



DISEASES OF CHILDREN FOR NURSES 



Nasal Syringing. — A soft-rubber nasal syringe is filled 
with an antiseptic solution. The same syringe should 




Fig. io8. — Method for syringing ear with fountain syringe. The lower end of bag 
should not be above level of auditory canal. 



not be used for more than one child unless thoroughly 
disinfected. 

Two positions may be used in nasal syringing. In 
diphtheria, scarlet fever, or any severe illness the child 
should not be removed from the bed. In such cases the 
head should be held on one side, the syringe being placed 



T'HERAPE UTICS 



445 



in the upper nostril. Then the child's head should be 
turned to the other side and the other nostril syringed. 
The alternate syringing should be continued until the nose 
is clean. When syringing, the water should run out of 
the opposite nostril or out of the mouth. 

The other method is to hold the child erect on the lap 
with the head inclined a little forward, the syringing being 
done by a person who stands behind. 




Fig. log. — Method for syringing nose. The syringe is introduced into upper nostril, 
the solution escaping from opposite nostril or mouth. 

Just as small an amount of pressure should be exerted 
when syringing the nose as possible, on account of the 
danger of forcing the infection into the Eustachian tube 
and causing an otitis media. 

At times a fountain syringe is used to irrigate the nose. 



446 



DISEASES OF CHILDREN FOR NURSES 



The bottom of the bag should not be over two feet 
above the child's head. 

Syringing of the Mouth and Pharynx. — A Davidson 

syringe may be used. If the pharynx is to be reached the 
nozzle is used as a tongue depressor. This should be 
placed at the angle of the mouth between the back teeth. 
The child should be held in the sitting posture, with the 
head incliaed forward. 

INHALATIONS 

Croup Tent. — A croup tent is made by placing a 
blanket over a frame in such a way that the entire bed is 




Fig. no.— Croup tent (J. P. C. Griffith). 



covered except for a small aperture at the side of the 
bed near the head which is required for ventilation. 



THERAPEUTICS 



447 



Blankets are used instead of sheets, as the latter are liable 
to catch fire. If a regular frame is not available, a good 
substitute can be made by erecting broom-sticks at the 
four comers of the bed and stretching a cord around the 
tops of the sticks. A very good tent can be improvised 
by throwing a large blanket over an umbrella. 

A croup kettle heated by a safety alcohol lamp should 
be placed upon the floor or on a low box beside the crib, 




Fig. iri.^-Croup kettle (J. P. C. Griffith). 

so that the end of the spout is just inside the tent at a 
level of the surface of the bed. 

The kettle is filled with boiling water and a dram of 
the compound tincture of benzoin may be added. The 
medicated steam vapor is very soothing in inflammations 
of the respiratory tract. Great care must be taken to 
prevent the tent or bed-clothes from catching fire. 



448 



DISEASES OF CHILDREN FOR NURSES 



STOMACH WASHING OR LAVAGE 

A soft rubber catheter, size i6, American scale (24 
French), with a large eye, is attached to rubber tubing 
by a glass joint. A funnel holding from 4 to 6 oz. 
is inserted in the end of the tube. The child should be 
held in a sitting posture, the body protected by a rubber 
sheet and the catheter moistened. While the tongue is 
depressed with the forefinger of the left hand the catheter 
is rapidly passed into the pharynx and down the esophagus. 
About ten inches of the catheter should be passed beyond 
the lips. When it has reached the stomach the funnel is 




Fig. 112. — Lavage. 

raised higher than the level of the infant's stomach 
and from 4 to 6 oz. of water poured into it from a 
pitcher. When this has run into the stomach the funnel 
is lowered and raised three or four times to remove any 
stomach contents, and then lowered below the level of 



THERAPEUTICS 



449 



the infant's stomach, which siphons out the water and 
stomach contents. This should be repeated until water 
runs clear. 

In older children the funnel should be refilled several 
times before siphoning out the contents, as the capacity 
of the stomach is greater. The water should be boiled 
and be at a temperature of iio° F. when used. When 




Fig. 113. — Gavage. 

the siphoned water runs clear remove the catheter from 
the stomach. To siphon successfully there must be some 
water remaining in the funnel when it is lowered. 

Care must be taken in giving both lavage and gavage 
that the child does not bite off and swallow the tube, for 
if such an accident happens there is nothing to do but open 

the stomach. 
29 



45 O DISEASES OF CHILDREN FOR NURSES 

GAVAGE (FEEDING BY STOMACH-TUBE) 

Gavage (Feeding by Stomach-tube) . — The same appara- 
tus is used as in stomach washing. The child should be 
wrapped in a blanket. Sometimes, where there is great 
resistance to the introduction through the mouth, it may 
be passed through the nose. In older children a mouth 
gag is often necessary. A good substitute is a large spool, 
the catheter being passed through the hole in the spool. 
After the tube has entered the stomach the funnel should 
be raised to allow the gas to escape. The food is then 
poured into the funnel; as soon as it has disappeared the 
tube is tightly pinched and quickly withdrawn to prevent 
food from trickling into the pharynx, which often causes vom- 
iting. In young infants, after removing the tube, it is well to 
keep the jaws open for a few moments to prevent gagging. 

Food given by gavage is often predigested; the intervals 
between feedings must be longer than under other cir- 
cumstances, and at times the stomach should be washed 

first. 

IRRIGATION OF THE COLON 

The child is placed upon its back, brought to the edge 
of the bed with the thighs flexed, and the buttocks slightly 
elevated. A soft rubber catheter is attached to an ordinary 
fountain syringe, the bag containing the water being 
hung 4 or 5 feet above the bed. The water should 
be at a temperature of 85° or 90° F. in ordinary 
cases; when there is shock normal salt solution at a tem- 
perature of 110° F. is used. The catheter should be 
greased before introduction and a small quantity of the 
water allowed to run off. It should then be placed 
within the sphincter when the water is allowed to flow. 



THERAPEUTICS 45 1 

This distends the rectum and allows further insertion to 
be accomplished easily. The catheter is pushed in 
slowly to a distance of 12 or 14 inches. Usually a pint 
and often a quart will be introduced before any water 
returns. The irrigation should be continued until the 
water returns clear; at times a gallon of water is used 
for a single irrigation. Gentle kneading of the abdomen 
should be continued during the procedure. At the end 
of the irrigation the rubber tube is detached and the 
water allowed to escape through the catheter. 

CONTINUOUS SALINE INJECTION 
This is used by many surgeons following operations on 
septic cases, especially appendectomy. It is useful when- 
ever children are greatly depleted. 

An ordinary fountain syringe is filled with normal salt 
solution at a tempera tmre of 115° to 120^ F. This is tied 
to the foot of the bed not over a foot above the level of the 
buttocks. Two hot-water bags, tied together, are sus- 
pended over the bag containing the salt solution, one on 
either side, and a blanket is wrapped around them. The 
hot-water bags can be refilled from time to time as they 
cool. The tube is then carried under the bed-covers and 
over hot-water bags, which lie on the bed, to the child's 
buttocks, which are elevated. Here it is attached to a 
specially prepared rectal tube (Murphy's tube) . A cath- 
eter can be used in place of a Murphy tube if the latter 
is not at hand. The catheter should be inserted from four 
to six inches in the rectum. If the tube is expelled it 
must be strapped in with adhesive plaster. 

The flow of the salt solution is controlled by a stop-cock 
or, better, a hemostat. The solution should drip (a drop at 



452 DISEASES OF CHILDREN FOR NURSES 

a time) into the rectum. By shutting off one-half or more 
of the caliber of the tube by means of the hemostat this 
can be regulated. 

The idea of giving the solution so slowly is to have it all 
absorbed. Usually, however, there is leakage, and the 
clothes must be changed frequently and the bed protected. 

The system of hot-water bottles will keep the solution 
at the proper temperature. When the solution is not 
retained a good plan is to give it for two hours, then dis- 
continue for the same length of time. 

ENEMATA 

An enema consists in the iujection of soapy water into 
the rectum. The water should be at a temperature of 
85° or 90° F 

High Enema. — A catheter should be attached to the 
nozzle of the fountain syriuge and thoroughly greased. 
A small amount of water should be allowed to run off 
before iatroduction ; then place the catheter within the 
sphincter and start the flow; this allows it to be pushed 
m further without doubling up. Where an immediate 
effect is desired the most efffcient enema contains one 
teaspoonful of glycerin. Oil enemas are useful where 
the fecal mass is hard and dry and expelled with difficulty. 

Low enemas are given in the same manner; the water 
is injected by the introduction of the nozzle of syriuge 
within sphincter, the catheter being unnecessary. 

Nutrient enemata are sometimes used. They should 
be peptonized. 

When drugs are given by enemata milk is sometimes 
used as the fluid. 



THERAPEUTICS 453 

HYPODERMICS 

The skin should be rubbed with alcohol and then 
pinched between the thumb and forefinger, and the needle 
plunged firmly into the subcutaneous tissue. Veins 
must be avoided. The solution is injected slowly. After 
the withdrawal of the needle the part should be kneaded 
with the fingers. If the drugs used are of an irritating 
nature hot sponges of cotton should be applied to the part. 
The hypodermic needle must be sterile. 

For the administration of gelatin solutions sterile " horse 
h3rpodermics " are used. The preparations must be 
injected slowly and the punctured wound covered with 
collodion. Antitoxin is sold in sterile hypodermic tubes. 
The method of introduction is the same. 

BACTERINES AND VACCINES 

These are emulsions of dead bacteria which are injected 
into the patient to stimulate phagocytosis, based on 
Wright's opsonic theory. 

Phagocytosis is the property of the white blood cor- 
puscles to destroy germs and to eliminate toxins or poisons. 

In many conditions it does a great deal of good. 

The technic of administration is the same as for any 
hypodermic injection. 

VAGINAL DOUCHING 

A fountain syringe with a catheter attached to the 
nozzle is used. The catheter should be sterile and 
greased before introduction into the vagina. The solutions 
used for douching are bichlorid of mercury, i: 10,000; 
potassium permanganate, 1:10,000; saturated solution of 
boric acid; and salt solution. They should be at a tem- 



454 DISEASES OF CHILDREN FOR NURSES 

perature of iio° F., and from one to two quarts are 
used. 

VAGINAL INJECTIONS 

Argyrol is the drug most often used. Three drams of 
a lo or 20 per cent, solution of argyrol are placed iii a 
glass syringe having a sterile rubber catheter attached 
to the nozzle. The parts are thoroughly cleaned and 
the solution injected. The catheter is quickly with- 
drawn and the vulva is held together for several minutes, 
when the solution is allowed to run out. Argyrol deeply 
stains all linens. It is sometimes administered in the 
form of vaginal suppositories. 

METHODS OF RESUSCITATION* 

When a person is shocked by electricity, overcome by 
coal or illuminating gas, rescued from drowning, poisoned 
by certain drugs or fumes, severely injured, or in a state 
of collapse from one of many other causes, he may ap-* 
parently be dead, but if there is. some one at hand who can 
start the proper methods of resuscitation at once, a 
human life may be saved. 

It is practically impossible for a person to recover if 
certain cells in the brain have been deprived of oxygen for 
a. period exceeding ten minutes, so within that space, of 
time lies his chance of life or death. 

A person dies from one of two causes : in the first .class, 
failure of the heart is primarily responsible for death, and 
in the. second, failure of the respirations. 

Heart Failure.— li the heart has ceased to beat there 
is no known practical agency by which it may be started 

* Robert S. McCombs in The Nurse, October, 1915. 



THERAPEUTICS 455 

again. However, though the patient is apparently dead, 
the heart may make a weak attempt at beating, so weak 
that respiration ceases from failure of the supply of 
oxygen to reach the respiratory center in the central 
nervous system. The oxygen, of course, is carried to 
this center by the blood and, when the failing heart can- 
not propel the blood-stream at its normal rate and volume 
the supply of fresh oxygen is diminished and the respira- 
tory center shuts down. Cessation of respiration itself 
will soon stop any attempts of the heart to beat. There- 
fore the most important single expedient in this class 
of cases is to re-establish respiration by means of arti- 
ficially forcing the victim to breathe, for in this way the 
vicious circle is broken. 

Respiratory Failure. — In collapse due to electric 
shock, coal or illuminating gas poisoning, and drowning, 
the function of respiration is either suddenly paralyzed 
or progressively depressed. The heart may not be 
affected at first to a degree which in itself would prove 
dangerous, but the interruption of the oxygen supply to 
the body will soon stop its action. In this class of cases 
artificial respiration is again indicated as the most im- 
portant factor in the treatment. 

The principal thing that we attempt to accomplish in 
all methods employed, for inducing artificial respiration 
is to force air in and out of the lungs in sufficient quanti,- 
ties to supply enough oxygen to maintain life and to 
stimulate the respiratory center to resume its function. 
Inhalation of oxyg'en in itself is always a good adjunct 
to artificial respiration; likewise rubbing the extremities, 
slapping the skin, surface, passing gauze saturated with 
ammonia beneath the nose (not so close that burning 



456 DISEASES OF CHILDREN FOR NURSES 

from the fumes may be a danger), assist in stimulating 
the respiratory center. 

It is also vital in every method to loosen the clothing 
so that movement of the chest will not be restricted and 
to clear mucus from the mouth, also to pull the tongue 
forward so as to give the air free passage. If necessary 
the jaw should be forced open, and it is always best to 
put some hard object between the teeth that the patient 
may not bite the tongue. Hot-water bottles should be 
placed about the victim if the temperature is subnormal 
or if other symptoms of shock are present after recovery 
takes place. 

In case of drowning, the water should be expelled 
from the stomach and lungs by placing the victim face 
downward across a barrel or similar object; thus, com- 
pression of the abdomen forces the water out. 

No method of artificial respiration, manually applied, 
will ventilate the lungs with as large an amount of air as is 
obtained in normal breathing. The Schafer, Silvester, 
Hall, and Howard methods, however, will sustain life. 
There are also on the market several machines for per- 
forming artificial respiration. These include the pul- 
motor. Doctor Brat's apparatus, the lungmotor, and the 
salvator. Doctor Meltzer of the Rockefeller Institute 
has pubhshed a description of an apparatus which he has 
given to the medical profession. 

Manual Methods of Artificial Respiration. — ^Artificial 
respiration has been given a great deal of scientific study 
during the past few years in an effort to standardize 
the methods to be employed and to simplify the manipu- 
lations required. It has been felt that the old Silvester 
method, which has proved its efficiency over a long 



THERA PE UTICS 45 / 

period of time, is too complicated for the average layman 
to grasp immediately; it is too difficult to apply correctly 
and, if not properly performed, it loses its value. This, 
together with the fatigue engendered by the necessary 
exertion on the part of the person manipulating the arms 
of the victim, makes a more simple and less tiresome 
method desirable. 

Through actual experience the Schafer or "prone- 
pressure" method has been found just as efficient and is 
very* much easier to apply. Scientific experiments have 
proved its value, and now it is being advocated as the 
proper method to employ. It was devised by Sir E. A. 
Schafer, of Edinburgh, and consists in laying the victim 
on his belly and applying pressure rhythmically on the 
loins and lower ribs. To get the best results the arms 
should be stretched forward above the head, and the face 
turned to one side so that breathing through the mouth 
and nose will not be embarrassed, and the operator 
should stand or kneel across the victim's back. In this 
position he places his hands over the lowermost ribs and 
upper portion of the loins and by bending forward, and 
in this, way throwing the weight of his body on his wrists, 
the victim's chest is compressed against the ground and 
the air is squeezed out of the lungs ; then by assuming the 
erect posture the pressure is removed and the natural 
elasticity of the chest causes it to expand spontaneously 
and respiration results. By repeatmg these movements 
rhythmically twelve times to the minute, a person can 
be kept alive almost indefinitely. The pressure should 
be appHed evenly, without sudden forcible movements, so 
that no injury to the ribs or liver will occur. 

The following figures, obtained by Henderson, show 



458 DISEASES OF CHILDREN FOR NURSES 

the amount of air interchanged in Silvester's and Schafer's 
methods, compared with the amount in natural breathing 
at the same rate as the artificial: Silvester's, 150-200 ex.; 
Schafer's (with arms stretched forward), 200-300 ex.; 
natural breathing, 500-600 c.c. 

Summed up, the advantages claimed for the Schafer 
method are (i) greater simplicity and ease of adminis- 
tering, (2) absence of trouble from the tongue falling 
backward and blocking the air-passages, (3) little danger 
of injuring the liver or breaking the ribs if pressure is 
gradually and not violently applied, and (4) larger 
ventilation of the lungs. 

In performing artificial respiration, if the child does 
not show any signs of returning vitality, do not be dis- 
couraged, but continue the motion regularly for at least 
one hour, summoning such assistance as you may need. 



ASPHYXIA IN THE NEWBORN 

At times the child fails to breathe after birth. Under 
such conditions it is necessary to stimulate the respiratory 
centers. This usually can be accomplished by slapping 
the child, pouring ether or cold water over the chest, and 
removing mucus from the mouth; or if these methods 
fail, by grasping the base of the ribs between the thumb 
and fingers, the thumb on one side of the body and the 
remaining fingers on the other; by firmly squeezing the 
fingers together the air is forced out of the lungs, and upon 
relaxing the fingers the chest expands, filling the lungs. 
The base of the ribs should be forced together in this 
manner at the rate of about thirty times to the minute. 



THERAPEUTICS 459 

HYPODERMOCLYSIS 

This is the introduction of normal salt solution under 
the skin. For this purpose is used a sterile fountain 
syringe or glass reservoir with a special needle attached 
to the end of the rubber tube. The needle of a "horse 
hypodermic" can be used. The bag is filled with the 
necessary quantity of normal salt solution, at a temperature 
of 120° F., which has been sterilized on three successive 
days. After the cold water has run off, the needle is 
plunged through the skin. The pectoral and gluteal 
regions are usually selected as the places for injections. 
When the needle is in place the normal salt solution is 
allowed to run slowly, and continued until the amount 
ordered, varying from i to 8 oz., has entered the sub- 
cutaneous tissues. A small collodion dressing is applied 
to the puncture. Use a sterile thermometer for taking 
temperature of salt solution. 

INTRAVENOUS INJECTIONS 

This consists of the introduction of normal salt solution 
into a vein. The physician usually selects a vein at the 
inner side of the elbow-joint. A bandage is tied tightly 
around the arm above the joint to engorge the vein. He 
dissects the vein away from the surrounding tissue and 
places a grooved director beneath it. A ligature of catgut 
is thrown around the vein, below the point of inserting the 
needle, and tied. A second ligature is placed in position 
above the point of insertion, but it is not tied until after 
the injection has been given. A sterile fountain syringe 
or glass reservoir is filled with the required amount 
(usually a quart) of normal salt solution, which has been 
sterilized on three successive days, and a hypodermoclysis 



460 DISEASES OE CHILDREN EOR NURSES 

or horse hypodermic needle attached to the end of the 
rubber tube. The normal salt solution should be at a 
temperature of 110° to 120° F. (use sterile ther- 
mometer). When the physician is ready to introduce 
the needle into the vein the solution is allowed to run; 
it should be running when it is introduced into the vein, 
as this avoids the entrance of air into the vessels, which 
is a very dangerous accident. The bandage should be cut 
as soon as the needle enters the vein. When the solution 
has run into the vein the upper ligature is tied before 
the needle is removed. The skin wound is then stitched 
and an aseptic dressing applied. 

The instruments needed in this operation are a scalpel, 
forceps, hemostats, grooved director, ligatures, and a foun- 
tain syringe with proper needle ; also roller bandage. The 
arm should be prepared as for an operation. 

EXTENSIONS FOR FRACTURES AND COXALGIA 

A strip of adhesive plaster, 2 inches wide, is cut long 
enough to extend from the outer portion of the knee or 
middle of the thigh to a point 2 inches below the sole 
of the foot and from there to the middle of the thigh or 
knee on the opposite side of the leg. The adhesive is 
applied to the outer portion of the leg, as far as the ankle- 
joint. It is not attached to the foot, and 4 inches 
are allowed for the loop around the foot. It is then 
carried to the opposite ankle-joint and applied to the 
inner side of the leg. A bandage starting at the ankle- 
joint is applied to the leg as far as the adhesive strips 
extend. 

A small block of thin wood, 3 inches long and 2 
inches wide, is covered with adhesive, a hole bored in the 
center, and the board placed in the middle of the loop 



THERAPEUTICS 



461 



below the foot and held in place by a strip of adhesive. 
Through the perforation in the block a wire is passed, 
which is firmly attached to the inner side of the block. 
The wire should run over a pully at the foot of the bed 
and have a four or five-pound weight attached at the 
base which should clear the floor by several inches. A 
wad of cotton is placed beneath the tendo Achillis to 
prevent pressure at this point. The foot of the bed is 
elevated to obtain counter-extension. 




Fig. 114. — Buck's extension apparatus. The foot of the bed is elevated to obtain counter- 
extension. 

Care must be taken in the removal of old adhesive 
strips that the skin is not pulled off with the plaster. 
Alcohol or ether will render this task easier. 



DRESSING FOR FRACTURE OF THE FEMUR IN 
CHILDREN OVER TWO YEARS OF AGE 

Hamilton Splint. — This is the best dressing to apply 
in childhood. It consists of (i) two long splints; the ex- 



462 



DISEASES OF CHILDREN FOR NLRSES 



ternal reaches Vom the axilla to the sole of the foot and 
the internal extends from the groin to the sole. They 
are 4 or 5 inches wide at the hip-joint and taper to 
3 inches at the ankle. (2) Two long bags filled with 
bran, the external reaching from the axilla to the ankle 
and the internal extending from the groin to the internal 
malleolus. (3) A Buck's extension apparatus applied as 
described above. (4) A sand-bag reaching from the axilla 
to the ankle along the uninjured side. 

Method. — A piece of unbleached muslin of sufficient 
length to reach from the axilla to the sole and a yard wide 




Fig. 115. — Hamilton splint. First apply a Buck's extension. The injured leg is 
held in position by bran-bags between wooden side-splints, a long sand-bag balances the 
dressing on the sound side, to which is tied the uninjured ankle. A shot-bag is placed 
over upper fragment of fractured bone. 

is placed beneath the child. At a point corresponding 
to the level of the groin the muslin is cut through half 
its width. The extension apparatus is applied and the 
bran-bags put in their proper places in close apposition 
to the leg. The splints are then laid on the edge of the 
muslin and folded in until they fit close to the bran -bags 
and hold them snugly to the leg. Three or four strips 
of bandage placed around the dressing keep the splints 



THERAPEUTICS 463 

in place. The sand-bag is placed along the uninjured 
side. The upper portion of the unbleached muslin, which 
has not been folded in by the internal splint, is then 
carried around the body, including the sand-bag, and over 
the external splint, to hold the upper end in position. 
A weighted shot -bag is placed over the upper fragment 
of the bone and the foot of the bed is elevated. 

The necessity of frequent changing of the dressings 
and clothing of the child, from contamination with urine 
and the stools, renders it necessary, at times, to apply a 
moulded pasteboard splint beneath the fractured thigh, 
which should extend upward as far as the waist and 
be firmly held in place. This method of dressing does 
away with the pain from motion which always attends 
the process of redressing. 

MOLDED PASTEBOARD SPLINTS 

Technic. — The pasteboard is cut in the proper shape 
and of the proper length, and dipped in hot water. When 




Fig. 116. — ^Jaw-cup, unfolded. A moulded pasteboard splint (Da Costa). 

thoroughly wet it can easily be moulded to the part, 
which shape it holds when dry. It should be padded 
with cotton before application. 

SPLINTS 

Splints are used to keep the broken fragments of bone 
in apposition after a fracture. 

According to the location of the fractured bone different 



464 



DISEASES OF CHILDREN FOR NURSES 



kinds of splints have been devised. The principal forms 
are as follows: shoulder-cap, for fracture of the upper 
portion of the humerus; the internal angular and anterior 
angular sphnts for fractures of lower end of humerus 




Fig. 117. — Bond's splint (Da Costa). 





Fig. 118.— Internal angular splint 
(Da Costa). 




Fig. 119. — Anterior angular splint 
(Da Costa). 



Fig. 120. — Shovilder-cap (Da Costa). 



and upper portion of the bones of the forearm; and the 
Bond spHnt for fracture of the lower portion of the 
bones of the forearm. 



FRACTURE-BOX 

This is a special box used for fractures of the lower 
portion of the leg. It is so constructed that the sides are 
movable and the foot-piece perforated. 



THERAPEUTICS 465 

A pillow is placed upon the bottom of the box, while 
the sides are down, upon which is rested the fractured 
leg in such a manner that the foot is held firmly at a right 
angle against the foot-piece of the box, being secured in 
this position by a strip of bandage through the perforations. 
A wad of cotton should be placed beneath the heel and 
sole of the foot. The sides of the box are then turned 




Fig. 121. — Fracture-box (Da Costa) 

up and held in the upright position by three or four 
strips of bandage surrounding the box. This causes 
the leg to be held firmly between the two sides of the 
pillow. 

AIR-BEDS AND CUSHIONS 

Air-beds are useful at times in injuries to the back. 
W ater-heds are also used. 

Air-cushions are very useful in relieving a part from 
pressure. 

PLASTER CASTS 

Piaster casts are very useful in childhood. They are 
used for fractures, for keeping joints immobile, and for 
keeping the bones straight after an osteotomy. Specially 
prepared bandages are used, which should be soaked in 
luke-warm water immediately before application. 
30 



466 DISEASES OF CHILDREN FOR NURSES 

FRAMES 

Frames are used in Pott's disease, in order that the 
backbone may be kept immobile. The child is placed 
upon the frame in such a position that the buttocks are 
situated at the opening in the canvas. This permits 
bowel movement without removal from frame. The 
child is held in position by unbleached muslin, which is 
attached to the two side bars of the frame and cut of 
sufficient length to extend from the axilla to the base of 




Fig. 122. — Modified Bradford frame. Devised by Dr. Fauntleroy. The daily tightening 
of the nuts A and B keeps apparatus rigid. 

the frame. This covering should be tightly drawn across 
the child and firmly attached to the opposite bar. 

The Bradford frame, or some of its modifications, is 
the best. Fauntleroy's modification permits of the taking 
up of the slack by daily tightening the nuts in the upper 
and lower bars. This saves the trouble of constant 
tightening of unbleached muslin. 

OILED-SILK JACKET 

This is a very good method of obtaining a mild, con- 
stant counter-irritation of the chest, formerly used exten- 
sively in cases of pneumonia and bronchitis. The jacket 
is prepared by cutting out three layers, according to the 
pattern shown on the following page. 



THERAPEUTICS 467 

The outer layer is oiled silk, the middle layer is cotton 
batting, and the inner layer gauze. For a child one year 







Fig. 123. — Pattern for oiled-silk jacket. 



of age the dimensions should be 12 by 12 inches. A 
properly prepared jacket should last about two weeks. 

STRAIT-JACKET 

When it is necessary, in very restless children, to con- 
trol their movements the strait-jacket is of use. 

It is made of unbleached muslin, double thickness, 
a yard wide and cut long enough to reach from one side 
of the bed to the other. It is attached to the frame of 
the bed on both sides and fastened securely enough to 
hold the child flat upon its back. Two armholes are 
cut at the proper level and distance apart, and these 
should be bound. A wad of cotton should protect the 
skin of the axillae from chafing. 

CUFFS AND HAND COVERS 

Some form of protection is necessary in children who 
have a tendency to pick at their dressings or to scratch 
irritating lesions of the skin. 

Celluloid cuffs can be purchased which should be well 
padded before being apphed. 

Pasteboard cuffs are made by cutting stiff pasteboard 
of sufficient length to extend from the armpit, or axilla, 



468 



DISEASES OF CHILDREN FOR NURSES 



to the wrist, and wide enough to encircle the arm. 
They should be well padded with cotton and held in 
place by a bandage. This form of dressing prevents the 
child from bending the elbow. 
A light metal covering for the hands is the best form 



1 






Fig. 124. — A light metal covering for hands which prevents children from scFatchihg 

sores. 

of protection. The illustration (Fig. 124) shows this 
metal covering and the same applied. 



MASKS 

Masks are useful in the treatment of skin diseases of 
the face. They are made so as to cover completely the 
head and face, small apertures being cut for the eyes, 



THERAPEUTICS 469 

nose, and mouth. It is the only means by which appHca- 
tions to the face can be properly applied. 



MASSAGE 

Massage is useful in infancy after attacks of infantile 
paralysis. The affected limbs should be massaged daily 
to increase the circulation to the part, so that the unaf- 
fected muscles will be under the most favorable conditions 
for hypertrophying or overdeveloping, upon which de- 
pends a fairly good use of the leg. 

In childhood, massage is one of the best measures to 
employ in chronic constipation. It should be practised 
twice a day, after retiring and in the morning. The 
proper method of giving massage in these cases is to use 
only the hand, without grease of any kind, rubbing the 
abdomen with a circular motion, the idea being to move 
the abdominal wall over the intestine, and in this way 
to excite peristalsis. 

In older children the same causes for massage exist 
as in the adult. 

ELECTRICITY 

Electricity has a limited scope in childhood. In paralytic 
conditions it is useful and should be applied in the same 
manner as in the adult. 

SKIAGRAPHY 

For the purposes of diagnosis, especially of fractures, 
the Rontgen ray is of the greatest use. Medicinally 
it is not employed. 



47 O DISEASES OF CHILDREN FOR NURSES 

DISINFECTION 

All discharges should be immersed in carbolic acid, 
1 : 40 ; bichlorid of mercury, i : 2000 ; or chlorinated lime 
of equal strength, and allowed to stand fifteen minutes. 
All bed-clothing should be thoroughly boiled for a half 
hour. 

Disinfection of Hands. — Remove all dirt from 
under and around nails. Nails and hands should be 
thoroughly scrubbed with soap and hot water. Immerse 
them in 95 per cent, alcohol for not less than one minute, 
then plunge the hands in a solution of bichlorid of mer- 
cury, 1:2000, or carbolic solution, 1:40, and thoroughly 
wash them for at least a minute. A clean wound should 
never be dressed after an infected wound. The hands 
should be disinfected between each dressing. 

Full bichlorid baths, 1:4000, should be taken while 
nursing contagious cases, and given to the patient before 
release from quarantine. 

Fumigation of the apartments, mattresses, hangings, 
clothing, etc. is accomplished by thoroughly sealing the 
room and introducing formalin gas through the keyhole. 

Disinfection of Excreta. — The stools and urine should 
be received in a vessel containing a disinfectant. An 
equal quantity of disinfectant to the size of the excreta 
should then be added and the whole thoroughly mixed, 
and allowed to stand for half an hour before emptying into 
the water-closet hopper. The bed-pan should contain 
disinfectant when not in use. It should be thoroughly 
rinsed in warm water before placing it beneath the child, 
otherwise the disinfectant might burn the buttocks. 



THERA PE UTICS 47 1 

DRESSING OF BURNS AND WOUNDS 

The burned or scalded area should be covered with 
lint saturated with a normal salt solution. 

All lacerated and punctured wounds should be thor- 
oughly cleansed with hot water and peroxid of hydrogen. 
They should be covered with a wet bichlorid or sterile 
normal salt solution dressing and wax-paper. 

PREPARATION FOR OPERATION 

Thoroughly scrub the part with tincture of green soap, 
shaving first, if necessary; rinse with sterile water and 
alcohol; then a solution of bichlorid of mercury, i : 2000. 
Cover with gauze wrung out of i : 4000 bichlorid of 
mercury, wax paper, and bandage. 

At the time of operation this process is repeated. 

Many surgeons use tincture of iodin spray to sterilize 
the skin. This is usually prepared by adding one part of 
tincture of iodin to three parts of water. It is sprayed 
upon the skin by means of an atomizer. The skin thus 
treated peels off with the dressings. 

CATHETERIZATION 

The hands should be thoroughly scrubbed and dis- 
infected. The external genitals should be scrubbed 
with tincture of green soap and water; washed with 
sterile water; then with 1:4000 bichlorid solution; then 
a second time with sterile water to remove all traces of 
bichlorid. 

Soft rubber catheters should be boiled for ten minutes. 
English and silk catheters should be immersed in i : 20 
carbolic solution for ten minutes; then thoroughly rinsed 
in sterUe water before introduction. 



4/2 DISEASES OF CHILDREN FOR NURSES 

When ready to catheterize, dip the end of the catheter 
in carboHzed oil, i : 40. If the catheter touches any 
part before entering the urethra it must be resteriUzed. 
This care is taken to avoid infection of the bladder. When 
removing catheter it should be pinched to prevent the 
urine remaining in it from running out. If a glass catheter 
is used the finger should be placed over the opening. 

ASPIRATION OF THE CHEST 

A large needle, or trocar, and cannula is used to pierce 
the chest-wall. The instrument used is attached by 
means of a rubber tube to a vacuum pump from which 
all the air must have been removed before the operation. 

The child should be prepared for operation in the 
usual way, the point of the proposed puncture having been 
previously determined. The instruments used should be 
sterilized. A small dressing is placed over the puncture. 




Fig. 125. — Paquelin's cautery. Note that the benzene is contained in the handle of 
the apparatus (W. E. Ashton). 

PAQUELIN CAUTERY 

The metal reservoir, containing a sponge, should be 
about one-third full of benzene. The platinum point to 



THERAPEUTICS 473 

be used is screwed into position, the tube from the reser- 
voir is sKpped over the handle, the point is heated in the 
lamp, is removed from the flame, and by compressing 
the bulbs previously connected with the reservoir, benzol 
vapor is forced into the point, which will heat up and 
can be maintained at any temperature by the rapidity 
with which the bulb is worked. 

METABOLIC BED 

The metabolic bed is a name applied to a specially 
arranged bed in which the child is suspended in such a 
way that every drop of urine and feces is saved. 

The quantitative analysis of the excreta, compared 
with the known intake, gives the results of metabolism 
in the body and determines the nitrogen balances. 



CHAPTER XX 

WEIGHTS AND MEASURES; ABBREVIATIONS 

SCALES OF WEIGHTS AND MEASURES 

APOTHECARIES' WEIGHT 

The pound {libra) ft), contains 12 ounces, 

ounce (uncia) ^ " 8 drams, 

dram (drachma) 3 " 3 scruples, 

scruple (scrupulum) 3 ''20 grains, 

grain {granum) gr. 

WINE MEASURE 

The gallon (congius) C contains 8 pints. 

pint (octarius) O " 16 fluidounces. 

fluidounce (uncia fluida) f^ " 8 fluidrams. 

fluidram (drachma fluida) f^ " 60 minims. 

minim (minimim) HX 



TABLE OF MUTUAL EQUIVALENTS OF WEIGHTS AND 

MEASURES 



ft). 




g 


^ 


9 


gr. 


I 


= 


12 


= g6-- 


= 288 = 


= 5760 






I 


= 8: 


= 24=:: 


: 480 








I :: 


I ^ 


= 60 

-- 20 


c 







I 


3 


m 


I = 


= 8 


= 


128 = 


1024 = 


61,440 




I 


= 


16 = 


-- 128 = 


7,680 








I ;^ 


8 = 
I = 


480 
60 



474 



WEIGHTS AND MEASURES; ABBREVIATIONS 475 

In prescription writing the scruple is rarely used at 
the present time. 

THE METRIC SYSTEM 

When the metric system is used, the quantities of 
liquids, as well as solids, are expressed by weight. 

The meter is the unit of length; the gram, of weight; 
and the liter, of volume. 

The prefixes, deca, hecto, kilo, derived from Greek 
numerals, are used to denote uicrease, and the prefixes 
deci, centi, milli, derived from the Latin numerals, to 
denote decrease. 



1000. 


= I kilometer. 


100. 


= I hectometer. 


10. 


= I decameter. 


I. 


= I meter. 


.1 


= I decimeter. 


.01 


= I centimeter. 



.001 = I millimeter. 

The cube of a centimeter is called a cubic centimeter, 
and is written cc, which term is used to denote capacity. 
It is used almost exclusively. Thus, instead of saying 
I decimeter, we say 100 cc, and instead of i deciliter, we 
say 100 cc. 

Relation Between the Apothecaries and the Metric 
System. — 



I meter 


= 39.39 inches. 


25 millimeters 


= I inch. 


I liter 


= 33.81 fluidounces, slightly over a quart. 


I gram 


= 151 grains 


.065 " 


= I grain. 


29.37 cubic centimeters 


= I fluid ram. 


4 


= 11; minims. 



476 DISEASES OF CHILDREN FOR NURSES 

Rule for Convertii^ Troy Weights into Grams. — 

{a) Reduce each quantity to grains, move the decimal 
point one place to the left, and subtract one-third. 

{h) Reduce each quantity to drams and multiply by four. 

To Estimate a Dose of a Different Fractional Part 
of a Grain from the Drug on Hand.— You are often 
ordered to give a dose of medicine of a different frac- 
tional part of a grain from the drug you have. Thus, 
you may be ordered to give gr. 4V of strychnin when 
the only solution on hand is one in which 10 minims 
equals gr. eV- To find out how much to give, multiply the 
denominator of the fraction of the solution on hand by 
the number of minims in which it is held in solution, and 
divide the result by the amount ordered. Thus, 



io 



10 



40)600(15 

40 

200 

200 

Give 15 drops. 

If quantity in a tablet is greater than required. 

The given dose is used as the numerator and the re- 
quired dose as the denominator, thus: 

The dose of a tablet is marked -^^-^ gr., and the re- 
quired dose is Y5-Q gr- 

100 —2 

15 3 

Therefore, two-thirds of the tablet is the required dose. 
The tablet should be dissolved in fifteen drops of distilled 
water and two-thirds, or ten drops, administered as the 
dose. ■ 



WEIGHTS AND MEASURES; ABBREVIATIONS 477 

To Obtain a Fractional Fart of a Minim. — At times J, 
J, or i minim may be ordered. To obtain the amount 
correctly, it is necessary to take 5 minims of the drug and 
add 20 minims of water, making 25 minims in all; then 
5 minims of this quantity will represent i minim of the 
drug. 

If I minim is desired, 15 minims of water should be 
added to the 5 minims representing i minim of the drug, 
making 20 minims in all; then 15 minims of this quantity 
will represent J minim of the drug. 

If \ minim is desired, 5 minims of the above will rep- 
resent the proper amount. 

If \ minim is desired, it is necessary to add 5 minims 
of water to the original 5 minims representing the drug, 
making 10 minims in all; then 5 minims of this quantity 
will represent \ minim of the drug. 

In emergencies, 2 drops of a drug can be estimated as 
representing i minim. By adding 6 drops of water, 
making 8 drops in all, and then taking 6 drops of this 
quantity, f minim may be obtained. Two drops of the 
above would represent J minim of the drug. By adding 
2 drops of the water to the 2 drops of the drug and taking 
2 drops of this quantity, \ minim may be obtained. If 
fractional parts of a drop are ordered, one-half of the 
above dilutions would represent the proper number of 
drops to use. 

Rule for Making Solutions of Definite Strengths. — 

{a) A I per cent, solution contains 5 (4.80) grains of the 
drug to each ounce of the solution. Therefore, a 2 per cent, 
solution contains 10 grains to the ounce; a 5 per cent, 
solution, 25 grains; a 10 per cent, solution, 50 grains, etc. 

(6) A 1 : 1000 solution contains 8 grains to a pint. 



4/8 DISEASES OF CHILDREN FOR NURSES 

Therefore, a i : 2000 solution contains 4 grains to a 
pint, a 1 : 4000 solution 2 grains and a i : 8000 solution 
I grain. The drugs are usually dissolved in water and 
labeled so many grains to the dram. 

DOMESTIC MEASURES 

I teaspoonful = i dram or 4 cc. 
I dessertspoonful = 2 drams or 8 cc. 
I tablespoonful =4 drams or 16 cc. 
I wine glass = 2 ounces. 

I tea cup = 5 ounces. 

I tumbler =11 ounces. 

TEMPERATURE 

There are two methods of expressing degrees of heat 
and cold. Centigrade and Fahrenheit, expressed by the 
symbols C. and F., respectively. 

The zero point of the Centigrade scale is the freezing- 
point of water, equal to 32° F. ; and the 100° point Cen- 
tigrade is the boiling-point of water, equal to 212° F. 

Rule for Changing Centigrade Temperatures to 

Fahrenheit. — 

Cx 9 

^ X 7,2 

5 f 
Example : 100 C. (boiling-point of water). 

C. 100° X 9 =900 ^5 =180 + 32 =212° F. 

To change Fahrenheit to Centigrade : 

F-32X5 _^ 

9 
Example : 212° F. (boiling-point of water). 

F. 212° — 32 =180 X 5 =900^9 = 100° C. 



WEIGHTS AND MEASURES; ABBREVIATIONS 479 



ABBREVIATIONS'* 



Abbreviation. 


Foreign word»or phrase. 


English equivalent. 


aa. 


ana 


Of each (z. e., equal parts). 


A. c. 


ante cibum 


Before meals. 


Ad 


ad 


To, up to. 


Add. 


adde, addatur, addantur Add, let there be added. 


Ad lib. 


ad libitum 


As much as desired. 


Ad part. 


ad partes dolente.s 


To the painful (aching) parts. 


dolent. 






Alt. dieb. 


alternis diebus 


Every other day, alternate days. 


Alt. hor. 


alternis horis 


Every other hour. 


Alt. noct. 


alternis noctibus 


On alternate nights, every other 
night. 


A. p. 


ante prandium 


Before meals. 


Aq. 


aqua 


Water. 


Aq. astr. 


aqua astricta 


Frozen vi^ater, ice. 


Aq. bull. 


aqua bulliens 


Boiling water. 


Aq. bull. 


aquae buUientis 


Of boiling water. 


Aq. dest. 


aqua destillata 


Distilled water. 


Aq. ferv. 


aqua fervens 


Hot water. 


Aq. font. 


aqua fontana 


Spring water. 


Aq. pluv. 


aqua pluvialis 


Rain water. 


Aq. pur. 


aqua pura 


Pure water. 


Aq. tep. 


aqua tepida 


Tepid water. 


Bisind., b.i.d. 


bis in die 


Twice a day, twice daily. 


BuU. 


bulliat 


Let it boil. 


C, Cent. 


Celsius, Centigrade 


Thermometer scale with 100 
degrees between the melting- 
point of ice and the boiling- 
point of water. 


C, cong. 


congius 


A gallon. 


Cap. 


cape, capiat 


Take (thou), let him take. 


Capsul. 


capsula 


A capsule. 


C.c. 


cubic centimeter 


A metric measure (16.23 min- 
ims) . 
One-hundredth of a gram {\ gr.). 


Cg., Cgm. 


centigram 


Chart. 


charta 


Paper. 


Chartul. 


chartula 


A small paper. 


Cib. 


cibus 


Food, victuals. 


C. m. 


eras mane 


Tomorrow morning. 


Cm. 


centimeter 


One-hundredth of a meter 
(0.3937 mch). 


C. n. 


eras nocte 


Tomorrow night. 


C. n. s. 


eras nocte sumendus 


To be taken tomorrow night. 


Coch. 


cochleare 


A spoonful. 


Coch. ampl. 


cochleare amplum 


Heaping spoonful. 


Coch. infant. 


cochleare infantis 


A child's spoonful. 


Coch. mag. 


cochleare magnum 


A tablespoonful. 


Coch. med. 


cochleare medium 


A dessertspoonful. 



Reprinted from The Nurse, October, 19 15, 



48o 



DISEASES OF CHILDREN FOR NURSES 



Abbreviation. 


Foreign word or phrase. 


English equivalent. 


Coch, parv. 


cochleare parvum 


A teaspoonful. 


Coct. 


coctio 


Boiling. 


Col. 


cola 


Strain. 


Colet. 


coletur 


Let it be strained. 


Collun. 


collunarium 


A nasal douche or wash. 


Collut. 


collutorium 


Mouth- wash. 


CoUyr. 


coUyrium 


An eye-wash. 


Comp. 


compositus 


Compound. 


Conf. 


confectio 


Confection. 


Contin, 


continuetur 


Let it be continued. 


Coq. 


coque, coquantur 


Boil, let them be boiled. 


Crast. 


crastinus 


Tomorrow. 


Cras mane 


cras mane sumendus 


To be taken tomorrow Tnorning, 


sumend. 






Cum 


cum 


With. 


C. V. 


cras vespere 


Tomorrow evening. 


Cyath. 


cyathus 


A glassful. 


Cyath. vin. 


cyathus vinarius 


A wineglassful. 


D. 


dies^ dosis, da 


A day, a dose, give. 


Decoct. 


decoctimi 


A decoction. 


Decub. 


decubitus 


Lying down. 


De d. in d. 


de die in diem 


From day to day. 


Deglut. 


deglutiatur 


Let it be swallowed. 


Det. in dup. 


detur in duplo 


Let twice as much be given. 


Dieb. alt. 


diebus alternis 


On alternate days. 


Dieb. tert. 


diebus tertiis 


Every third day. 


Dil. 


dilue, dilutus 


Dilute (thou), diluted. 


Dim. 


dimidius 


One-half. 


D, in p. aeq. 


divide in partes aequales 


; Divide into equal parts. 


Divid. 


dividendus 


To be divided. 


Dolor, dur. 


dolore durante 


While the pain lasts. 


Dr., 3 


drachma 


A dram (60 grains'). 


D. t. d. 


dentur tales doses 


Let such doses be given.. 


Ejusd. 


ejusdem 


Of the same. 


Empl. 


emplastrum 


Plaster. 


En,, Enem. 


enema 


A clyster or enema. 


Et 


et 


And. 


F. 


fac 


Make. 


F., Fahr. 


Fahrenheit 


Thermometer scale with 180 
degrees between the melting- 
point of ice and the boiling- 
point of water. 


Feb. dur. 


febre durante 


While the fever lasts. 


Ferv. 


fervens 


Boiling. 


F. h. 


fiat haustus 


Let a draft be made. 


Filt. 


filtra 


Filter. 


Fluid., Fid. 


fluidus 


Liquid. 


Fldr. 


drachma fluida 


Fluidram. 


Flor. 


flores 


Flowers. 


Fl. oz. 


uncia fluida 


Fluidounce. 


F. m. 


fiat mistura 


Let a mixture be 'made. 



WEIG 


HTS AND MEASURES; ABBREVIATIONS 48 1 


Abbreviation. 


Foreign word or phrase. 


English equivalent. 


Fol. 


folia 


Leaves. 


F. pot. 


fiat potio 


Let a potion be made. 


F.-pil. 


fiant pilulae 


Let pills be made. 


Fract. dos. 


fracta dosi 


In divided doses. 


Ft. 


fiat, fiant (pi.) 


Let it or them be made. 


Ft. mas. div. 


fiat massa dividenda 


Let a^ pill-mass be made and 


in pil. 


in pilulas 


divided into pills. 


Ft. pulv. 


fiat pulvis 


Let a powder be made. 


Garg. 


gargarisma 


A gargle. 


Gm. 


gram, gramme 


A metric weight (15.437 grains). 


Gr. 


granum, grana 


A grain, grains. 


Gtt. 


gutta, guttae 


A drop, drops. 


Guttat. 


guttatim 


By drops. 


H. 


hora 


An hour. 


Haust. 


haustus 


A draft. 


Hor. decub., 


hora decubitus 


At bedtime. 


H. d. 






Hor. som.. 
H. s. 

Ind. 


hora somni 


At the hour of sleep. 


in dies 


Daily. 


Infus. 


infusio 


An infusion. 


Injec. 


injectio 


An injection. 


L. 


liter 


A metric weight (33.816 fluid- 
ounces). 


Lb., ft). 


libra 


A pound. 


Linim. 


linimentum 


A liniment. 


Liq. 


liquor 


A solution. 


Lot. 


lotio 


A lotion. 


M. 


misce, meter, meridies, 


Mix (thou), French unit of 




mistura 


length (39.37 inches), noon, 
mixture. 


Mac. 


macera 


Macerate. 


Man. 


manipulus 


A handful. 


Man. pr. 


mane primo 


Early in the morning. 


M. ft. 


mistura fiat 


Let a mixture be made. 


Mg., Mgm, 


milligramme 


A metric weight (g^ grain). 


Mic. pan. 


mica panis 


Bread crumb. 


Min., TiJi 


minimum 


A minim. 


Mist. 


mistura 


A mixture. 


Mm., mm. 


millimeter 


A metric linear measure (^ 
inch). 


N. B. 


nota bene 


Note well. 


No. 


numero, numenis 


In number, a number. 


Noct. 


nocte 


At night. 


Noct. 


nocte maneque 


At night and in the morning. 


maneq. 






Non repetat. 


non repetatur 


Do not repeat. 


O. 


octarius 


A pint (§xvj). 


01. 


oleum 


Oil. 


Omn. bih. 


omni bihora 


Every two hours. 


Omn. hor. 


omni hora 


Every hour. 



31 



482 



DISEASES OF CHILDREN FOR NURSES 



Abbreviation. 


Foreign word or phrase. 


English equivalent. 


Omn. mane, 

0. m. 
Omn. noct. 

0. n. 
Omn. quar. 


omni mane 


Every morning. ^ 


omni nocte 


Every night. 


omni quadrante hora 


Every quarter of an hour. 


hor. 






Ov. 


ovum 


An egg. 


Oz., S 


luicia 


Ounce. 


P. ^. 


partes asquales 


In equal parts. 


Part. vie. 


partitis vicibus 


In divided doses, divided by 
turn. 


Per 


per 


Through, by means of, very. 


Pil. 


pilula 


A pill. 


Pocul. 


poculum 


A cup. 


Post cib. 


post cibum 


After meals. 


Pot. 


potio 


A potion. 


P.p. 


post prandium 


After meals. 


Ppt. 


praecipitatum 


Precipitate. 


P. r. n. 


pro re nata 


When required. 


Pulv. 


pulvis 


A powder. 


q. I h. 


quaque hora 


Every hour. 


q. 2 h. 


quaque secunda hora 


Every two hours. 


q. 3h. 


quaque tertia hora 


Every three hours. 


q. 4h. 


quaque quarta hora 


Every four hours. 


Q.s. 


quantum sufficit 


A sufficient quantity. 


Quotid. 


quotidie 


Daily. 


^ 


recipe 


Take (thou). 


Rad. 


radix 


Root. 


Redig. in 


redigatur in pulverum 


Let it be reduced to powder. 


pulv. 






Red. in pulv. 


reductus in pulverum 


Reduced to powder. 


Rep. 


repetatur 


Let it be repeated. 


S. A. 


secundum artem 


According to art. 


Sat. 


saturatus 


Saturated. 


Scat. 


scatula 


A box. 


Scr., 9 


scrupulus 


A scruple (20 grains). 


Sem. 


semen 


Seed. 


Seq. luce 


sequenti luce 


The following day. 


Sp. fr. 


spiritus frumenti 


WOiisky. 


Sig. 


signa, signetur 


Write (thou), let it be marked. 


Sin. 


sine 


Without. 


Sinap. 


sinapis 


Mustard. 


Solut. 


solutio 


A solution. 


S. o. s. 


si opus sit. 


If necessary. 


Sp. gr. ^ 


gravitas specificus 


Specific gravity. 


Spt., spir. 


spiritus 


Spirit. 


Ss. 


semis, semissis, semi- 


A half. 


St. 


stet, stent 


Let it or them stand. 


Stat. 


statim 


Immediately. 


Su. 


sumet 


Let him take. 


Sum. 


sumatur, sumantur 


Let it (them) be taken. 



WEIGHTS AND MEASURES; ABBREVIATIONS 483 



Abbreviation. 


Foreign word or phrase. 


English equivalent. 


S. V. 


spiritus vini 


Alcoholic spirit. 


S. V. g. 


spiritus vini gallici 


Brand^^ 


S. V. r. 


spiritus vini rectificatus 


Alcohol. 


S. V. t. 


spiritus vini tenuis 


Proof spirit. 


Syr. 


syrupus 


Syrup. 


Tab. 


tabella 


A tablet. 


Tal. 


talis, tales 


Such a one, such ones. 


T. d., t. i. d. 


ter die, ter in die 


Three times a day, thrice daily. 


Tinct., Tr. 


tinctura 


Tincture. 


Trit. 


tritura 


Triturate. 


Troch. 


trochiscus, trochisci 


A lozenge, troche, lozenges. 


Unc, S 


uncia 


An ounce. 


Ung. 


unguentum 


An ointment, unguent. 


Ut diet. 


ut dictum 


As directed. 


Ves. 


vesica 


The bladder. 


Vesic. 


vesicula, vesicatorium 


A bhster. 


Vin. 


vinum 


Wine. 


Vitel. ov. 


vitellus ovi 


Yolk of egg. 


V. S. 


solutio + volume + 


Volumetric solution (one con- 




metric 


taining in each liter [quart] a 
definite amount of any re- 
agent), also called standard 
solution. 



CHAPTER XXI 



MEDICAL TERMINOLOGY 



Prefix 


Definition 


Example 


A 


absence of 


asepsis. 


dys 


painful 


dyspepsia. 


end 


the lining 


endocarditiso 


hemo 


blood 


hemothorax. 


hydro 


water 


hydrocele. 


hyper 


above 


hyperacidity. 


hypo 


beneath 


hypodermic. 


macro 


large 


macroglossia. 


micro 


small 


microscope. 


peri 


around 


pericardium. 


pneumo 


air 


pneumothorax. 


pyo 


pus 


pyogenic. 


Suffix 


Definition 


Example 


Algia 


pain 


neuralgia 


cele 


a tumor 


hydrocele. 


ectomy 


cutting out 


appendectomy. 


esthesia 


feeling 


hyperesthesia. 


gogue 


drugs causing in- 






crease of flow 


cholagogue. 


itis 


inflammation of 


appendicitis. 


lithiasis 


stone in 


nephrolithiasis. 


odynia 


painful 


pleurodynia. 


ology 


study of 


bacteriology. 


orrhea 


copious discharge 


diarrhea. 


otomy 


cutting into 


gastrotomy. 


phagia 


swallowing 


dysphagia. 


pepsia 


digestion 


dyspepsia. 


phonia 


speech 


aphonia. 


Name 


Root Word 


Inflammation of 


"Brain 


encephalos 


encephalitis. 


ear 


ous, otos 


otitis. 


gland 


aden 


adenitis. 


heart 


cardia 


endocarditis. 


intestine (large) 


colon 


colitis. 


intestine (small) 


enteron 


enteritis. 


kidney 


nephron 


nephritis. 


484 







MEDICAL TERMINOLOGY 



485 



Name 


Root Word 


Inflammation of 


liver 


hepar 


hepatitis. 


mouth 


stoma 


stomatitis. 


muscle 


mys, myos 


myositis. 


nerve 


neuron 


neuritis. 


nose 


rhis, rhinos 


rhinitis. 


rectum 


procto 


proctitis. 


skin 


derma 


dermatitis. 


stomach 


gaster 


gastritis. 


tongue 


glossa 


glossitis. 



GLOSSARY 

Abdomen. — The portion of the trunk extending from the chest to 
the pelvis. 

Abnormal. — Not conforming to the general rule of nature. 

Abduct. — To draw from median line. 

Adduct. — To draw toward center. 

Abrasion. — The rubbing off of the skin or mucous surfaces by injury. 

Adenitis. — Inflammation of a gland. 

Adenoid. — A polypoid growth in the pharynx, back of the nose. 

Adipose. — Consisting of fat. 

Adolescence. — The period between puberty and full development. 

Aerated. — Exposed to the action of fresh air. 

Albumen. — ^White of egg. 

Alkaline. — Having properties the opposite to those of an acid. 

Alopecia. — Baldness. 

Alveoli. — Air cells of the lungs. 

Analyze. — To ascertain the composition of. 

Anasarca. — General dropsy. 

Anatomy. — The study of the different tissues and organs of the body. 

Anemia. — A decrease in the blood constituents. 

Anesthetic. — Pertaining to the loss of sensation. 

Ankylosis. — A locking of a joint from injury or disease. 

Anomalies. — Marked deviation from the normal. 

Anorexia. — Loss of appetite. 

Antiseptic. — Having the power to destroy bacteria and to prevent 
their growth. 

Anus. — The external opening of the rectum; 

Areola. — A colored ring around an object. 

Arthrepsia. — Marasmus. 

Asepsis.-— Absence of bacteria. 

Asphyxia. — Suffocation. 

Assimilate. — The process of transforming food into such a nutrient 
condition that it may be taken up by the blood. 



486 DISEASES OF CHILDREN FOR NURSES 

Atony. — Want of power, especially muscular power. 
Atresia. — The absence of the natural opening to a normal canal. 
Auricle. — The external ear. 

Autopsy. — An examination of the organs and tissues of the body 
made after death. 

Bacteria. — Germs. A low form of plant life. They multiply very 
rapidly. 

Batting. — Cotton or wool arranged in layers for quilting. 

Bicuspids. — The fourth and fifth teeth from the middle. 

Bladder. — The reservoir for the urine. 

Bronchial Tubes. — The air-passages from the windpipe or trachea 
to the air-cells of the lungs. 

Cachexia. — A very low condition of nutrition due to some serious 
disease. 

Calorie. — The amount of heat required to raise i gram of water to 
1° of heat Centigrade. 

Canine Teeth. — The eye teeth, third from the middle. 

Canthus. — The angle formed by the upper and lower eyelids at the 
internal and external extremity of the palpebral fissure. 

Carbohydrates. — Sugars. 

Caries. — Death of a bone. 

Caseate. — To break down and form a cheese-like mass, seen in tuber- 
cular processes. 

Casein. — The ingredient of milk which constitutes most of the curd, 
and is the chief source of proteid. 

Catharsis. — To purge. 

Catheter.— A hollow, flexible rubber tube used to draw off the urme 
from the bladder (catheterization). 

Cell.— The smallest division of animal life. The entire body is 
composed of millions of cells. 

Cereals.— The grain plants, such as wheat, rye, barley, etc. The 

seed is used for food. 

Cerumen. — The wax of the ear. 

Cicatrix. — Scar tissue. 

Circulation.— The flowing of the blood through the body. 

Clonic— The term given to intermittent convulsions. 

Coagulate.— To thicken, clot, or curdle. 

Coalescence.— The union of two or more parts of a thing. To 

flow together. 

Colic— Severe griping pain in the abdomen. 



MEDICAL TERMINOLOGY 487 

Colostrum. — The milky fluid which can be pressed from the breasts 
of a pregnant woman, and which flows for the first three days after the 
birth of the child. 

Communicable. — Contagious. 

Complication. — A condition occurring during the course of a disease. 

Compoimd. — Composed of two or more ingredients. 

Compress. — A folded cloth, wet or dry, applied to a part for the 
relief of inflammation, or to prevent a hemorrhage. 

Condiment. — Substances used to give relish to food. 

Congenital. — Being present at the time of birth. 

Congestion. — An abnormal accumulation of blood in an organ or 
part of the body. 

Constipation. — Difl&cult or infrequent bowel movements. 

Constriction. — The state of being squeezed. 

Contagious. — Capable of direct communication. 

Contaminated. — Rendered impure by contact. 

Contusion. — A bruise. 

Convalescence. — The gradual return to health after sickness. 

Convulsion. — A violent and involuntary muscular contraction, or 
series of contractions. 

Cornea. — The transparent anterior portion of the eyeball. 

Coryza. — Cold in the head. 

Coxalgia. — Tubercular hip-joint disease. 

Crepitus. — A grating, crackling sound. 

Curdle. — The formation of curds. 

Curds. — The thickened portion of milk. 

Curetment. — Scraping of a part to remove diseased tissue. 

Cyst. — A cavity containing fluid and surrounded by a capsule. 

Cystitis. — Inflammation of the bladder. 

Dandruff. — Small scales from the scalp. 

Deaf-mutism. — The condition of being both deaf and dumb. 

Debilitated. — Weakened. 

Decoction. — The water in which a substance has been boiled. 

Decubitus. — The position of a patient in bed. 

Defecate. — The act of having a bowel movement. 

Deformity. — Unnatural shape. 

Degeneracy. — The tendency to deteriorate. 

Deglutition. — The act of swallowing. 

Deleterious. — Injurious. 

Delivery. — The birth of a child. 

Dentition. — The process of cutting teeth. 



488 DISEASES OF CHILDREN FOR NURSES 

Dermatitis. — Inflammation of the skin. 

Desquamate. — To shed the skin. 

Development. — A gradual growth through progressive changes. 

Diagnosis. — Recognition of a disease. 

Diastole. — The period when the chambers of the heart dilate after 
the period of contraction. Occurs after each heart-beat. 

Digestion. — The process of changing the food from the form in 
which it enters the body to that in which it is absorbed by the blood. 

Disinfection. — Rendering free from germs. 

Diurnal. — Daily. 

Douche. — A jet of water entering a cavity of the body. 

Dyspepsia. — Chronic indigestion. 

Ecchymosis. — Extravasation of blood into surrounding tissues. 

Edema. — Dropsical swelling. 

Effervescent. — Bubbling up, with the giving off of gas bubbles. 

Effusion. — The pouring out of a serous or bloody fluid into the 
tissues or cavities of the body. 

Embolus. — A particle of fibrin or other material brought by the 
blood current and forming an obstruction within an artery at its place 
of lodgment. 

Embryo. — The unborn child before the fourth month of pregnancy. 

Emulsion. — A mixture of an oily substance with a liquid. 

Enema. — An injection into the rectum. 

Epidermis. — The outer layer of the skin. 

Epistaxis. — Nose-bleed. 

Eruption. — A rash. 

Eustachian Tube. — A duct running from the middle ear to the 
pharynx. 

Evaporation. — Converting into vapor. 

Excretion. — A discharge of waste products. 

Exhale. — To breath out. 

Expiration. — The emptying of the lung of air. 

Fat-free Milk. — Milk from which all the fat has been removed. 

Feces. — The stools. Matter expelled from the intestines by way 
of the rectum. 

Fetus. — The unborn child after the fourth month of pregnancy. 

Fissures. — Cracks in the skin, or mucous membrane. 

Flatulence. — The presence of gas in the stomach and intestines. 

Flocculent. — Flaky. 

Fomentation. — Flannel cloths rung out of hot water and placed 
on the body as a means of applying moist heat. 



MEDICAL TERMINOLOGY 489 

Fontanel. — The soft spot in a child's head, caused by the non-union 
of the bones. 

Formula. — A list of the names and quantities of the ingredients of 
a mixture. 

Function. — The mode of action of an organ. 

Funmcle. — A boil. 

Genital. — Pertaining to the organs of reproduction. 
Gland. — An organ of the body that secretes substances of use to the 
system or casts off waste matter. 

Hemorrhage. — Bleeding. 

Hemorrhoids. — Piles. 

Hepatization. — Liver-like. Used in describing the lung in pneu- 
monia. 

Hernia. — A rupture. The protrusion of the internal organs from 
their natural position. 

Hydrotherapy. — Treatment by means of water. 

Hygiene. — The science of preserving health. 

Hypertrophy. — To enlarge by overgrowth. 

Icterus. — Jaundice. 

Idiocy. — A lack of mental understanding. 

Imbecile. — One who is mentally weak. 

Incisors. — The four front teeth of each jaw. 

Incubator. — An apparatus for preserving the life of a premature 
infant. 

Infected. — Brought in contact with bacteria. 

Inherent. — Instinct. The ability to perform certain acts without 
knowledge of the reason and without previous training of the individual. 

Insomnia. — Sleeplessness. 

Inspiration. — The act of filling the lungs with air. 

Intermittent. — Ceasing at intervals. 

Interstitial Tissue. — The supporting tissue or framework of an 
organ or structure of the body. 

Isolation. — The complete separation from other individuals. 

Ktimiss. — Fermented milk. 

Labor.— Childbirth. 
Laceration. — A cut. 
Lancinating. — Shooting. 



490 DISEASES OF CHILDREN FOR NURSES 

Latent. — Hidden. 

Laxative. — A medicine that moves the bowels gently. 

Leukocytosis. — An increase in the number of white blood corpuscles 
in the circulation. 

Ligament. — A band of tissue binding two parts together. 

Lime-water. — A solution of lime in water. 

Loins. — The lower part of the back and region of the hips. 

Lubricant. — An oily material used to make two surfaces glide smoothly 
over one another. 

Malaise. — A feeling of weakness. Listlessness. 

Manipulation. — The act of handling or working with the hands. 

Massage. — A rubbing or kneading of the muscles. 

Mastication. — The act of chewing. 

Membrane. — A thin lining tissue. 

Membranous Croup. — Diphtheria of the larynx. 

Meningitis. — An inflammation of the membranes covering the 
brain and spinal cord. 

Microbe. — A germ. 

Micturition. — The act of urinating. 

Milk Sugar. — A sugar made by the evaporation of the whey of milk. 

Milk Teeth.— The first set of teeth. 

Minim. — About a drop. One-sixtieth of a fluid dram. 

Molars. — The back teeth. 

Morbid. — Diseased. 

Morbid Anatomy. — The study of diseased tissues. 

Mortality. — The frequency of death. 

Mucous Membrane. — The lining membrane of all passages and 
cavities that come in contact with the air. 

Mucus. — A slimy fluid from the mucous membrane. 

Navel. — The umbilicus. 

Necrosis. — Death of a structure or tissue. 

Nephritis. — Inflammation of the kidney. Bright's disease. 

Neural. — ^Pertaining to a nerve. 

Neuralgia. — Pain along the course of a nerve. 

Neurosis. — A nervous functional disease. 

Neuro tic . — ^Nervous. 

Nevus. — A birth-mark. 

Nitrogenous Food-stuffs. — Meats, potatoes, and similar foods. 

Nocturnal. — Pertaining to night. 

Normal. — ^According to the rule of nature. 



MEDICAL TERMINOLOGY 49 1 

Obstetrics. — The management of childbirth. 
Occluded. — Closed. 
Opaque. — Not transparent. 
Organism. — The body as a whole. 
Organize. — The conversion into living tissue. 

Palatable. — Agreeable to the taste. 

Parasites. — Insects living on animals, such as lice. 

Paroxysm. — A spasm. 

Paroxysmal . — Spasmodic. 

Parturition. — Childbirth. 

Pasteurization. — The heating of milk to 167° F. to destroy germs. 

Pathology. — The science of the changes which take place in the 
structure of the body in disease. 

Patulous. — Open. 

Pelvis. — The bony basin supporting the abdominal viscera. 

Percentage. — Rate per hundred. 

Perforation. — Used to denote the occurrence of a hole into an organ 
or through the bowel. 

Period of Incubation. — The time elapsing between the introduction 
of bacteria into the body and the appearance of the symptoms of the 
disease. 

Periodic. — Recurring at intervals. 

Peristalsis. — The worm-like movements of the intestines by which 
the feces are moved. 

Peritonitis. — An inflammation of the membrane lining the abdominal 
cavity. 

Pertussis. — Whooping-cough. 

Petechiae. — Hemorrhagic spots in the skin. 

Phenomenon. — A thing that is observed. 

Physiology. — The science of the functions of the different organs. 

Placenta. — The attachment of the umbilical cord to the inner side 
of the womb. The "after-birth." 

Pneumonia. — Inflammation of the lungs. 

Polyp. — A tumor composed of mucus. 

Pores. — The openings of the sweat-glands in the skin. 

Poultice. — A hot, soft mass, used to apply moist heat or to remove 
odor. 

Predisposition. — A tendency to. 

Pregnancy. — The carrying of the child by mother before birth. 

Premature. — Before full term. 



492 DISEASES OF CHILDREN FOR NURSES 

Prophylaxis. — Measures to prevent the development or spread of 
disease. 

Proteid. — The albuminous foods; the nourishing part of milk, eggs, 
and meat. 

Pruritus. — Itching. 

Puberty. — The period of life at which an individual becomes capable 
of producing children. 

Pubic. — Pertaining to the front of the pelvis. 

Puerperium. — The period immediately following childbirth. 

Pulse-rate. — The number of beats per minute. 

Purgative. — A medicine that cleans out the bowels. 

Quarantine. — The guarding of a building which houses a contagious 
case, so that no one can enter or leave. 

Rash. — A breaking out on the skin. 

Ratio . — Proportion. 

Reaction. — The return to normal after collapse. The return to 
warmth after a chill. 

Rectum. — The lower end of the intestines. 

Regurgitation. — Vomiting of mouthfuls. 

Relax. — To make less rigid. 

Remittent. — Temporary disappearance. 

Respiration. — The act of breathing. 

Respiratory Rate. — The number of respirations per minute. 

Resuscitate. — To revive. 

Rickets. — A disease of childhood characterized by deformity of the 
bones and changes in the liver and spleen. 

Rigor.— Chill. 

Rigor Mortis. — The stiffening of the muscles after death. 

Rotheln. — German measles. 

Rubella. — Measles. 

Rubeola. — Measles. 

Saliva. — Secretion present in the mouth. 

Saturated Solution.— A solution of a substance in which no more 
of that substance can be dissolved. 

Sclerosis. — Hardening of a part due to overgrowth of fibrous tissue. 

Scrofulous. — Tubercular. 

Scurvy. — A disease due to a lack of nourishing diet. 

Secretion. — The substance produced by glandular action. 



MEDICAL TERMINOLOGY 493 

Sedentery. — Sitting. 

Sepsis. — Poisoning by germs. 

Sequel. — A condition which appears after a disease. 

Shock. — The period of collapse following an accident or operation. 

Sinus. — Discharging channel from an abscess cavity. 

Sitz Bath. — Sitting in water covering the hips. 

Sordes. — Crusts that accumulate on the teeth. 

Spastnodic.^ — Occurring in spasms. 

Specific Remedy. — One that has a distinct curative influence on an 
individual disease, as quinin in malaria. 

Sputum. — Spittle. 

Sprain. — A tearing of the ligaments around a joint. 

Stenosis. — Constriction or narrowing of a channel. 

Sterilize. — To render free from germs. 

Sterile. — Absence of germs. 

Stimulate. — To excite action. 

Stomach Teeth. — The two milk teeth on either side of the four 
lower incisors. 

Striae. — Lines or furrows. 

Structure. — Construction of parts. 

Stupe. — A cloth rung out of hot water and used for applying moist 
heat. 

Suppression. — A stoppage of a discharge. 

Symptom. — A sign of a disease. 

Temperature. — The degree of heat. 

Tetanus. — Lock-jaw. 

Tissue. — A collection of cells of the body doing the same work. 

Toxin. — A poison. 

Traumatism. — An injury. 

Tumor. — An abnormal swelling. 

Umbilical Cord. — The cord by which the infant is attached to the 
placenta. It enters the child's body at the umbilicus or navel. 
Unhygienic— Contrary to the laws of health. 
Urine. — The excretion of the kidneys. 
Uterus. — The womb. 

Vapor Bath. — A bath in vapor used to produce sweating. 
Vagina. — The opening in the female which extends from the womb 
to the outer parts. 



494 DISEASES OE CHILDREN FOR NURSES 

Varicose Veins. — Swollen, thickened veins. 

Venous Stasis. — Engorgement of the veins with blood. 

Ventilation. — The process of replacing foul air with pure. 

Viscera. — The organs of the body. 

Vitality. — Vigor. 

Vulva. — The external genitals of the female. 

Weaning. — Removing the nursing infant permanently from the 
breast. 

Whey. — The part of milk which remains fluid after the curds have 
formed. 



INDEX 



Abbreviations, 479 
Abscess, cerebral, 215 

in Pott's disease, 304 

ischiorectal, 164 

of liver, 166 

of lung, 107 

psoas, 304 

retropharyngeal, 126 
Accommodation, 250 
Achondroplasia, 216 
Adenitis, 263 

tubercular, 26, 307 
Adenoid, 121 
Air-beds, 465 
Air-cushions, 465 
Airing of newborn babe, 40 
Albumin and milk, 366 

in urine, test for, 255 

water, 366 
Albmninuria, 234 
Alkaline baths, 440 
Amyloid kidney, 242 
Anemia, 25, 192, 193 
Anesthesia, 205 

in hysteria, 219 
Aneurysm, 25, 190 
Angina, follicular, 120 

Vincent's, 123 
Anginoid scarlet fever, 316 
Animal parasites, 204 
Ankle clonus, 204 
Ankylosis, 305 
Anorexia, 114 
Antidotes of poisons, 410 
Antigen, syphilitic, 277 
Antiseptic poultices, 432 
Antitoxin in diphtheria, 328 
Anuria, 233 
Anus, atresia of, 22, 142 

fissure of, 164 



Aortic insufficiency, 183 

stenosis, 183 
Apex-beat, 173 
Aphasia, 216 
Aphthous stomatitis, 116 
Apoplexy, 315 
Apothecaries' weight, 474 

and metric system, relation be- 
tween, 475 
Appendicitis, 155 
Appetite in digestive diseases, 113 
Apple gruel, 368 
Arachnoid, 202 
Arrow-root gruel, 370 

with egg, 371 
Arteriosclerosis, 25, 190 
Arthritis, tubercular, 306 
Arthropathies, 205 
Artificial feeding, 376 

respiration, 454 

manual methods, 456 
Ascaris lumbricoides, 162 
Ascites, 168 

Asphyxia, emergency treatment, 
422 

in newborn, 19, 458 
Aspiration in empyema, 87 

of chest, 472 

pneimionia, 107 
Asthma, 77 

emergency treatment, 422 
Astigmatism, 250 
Atelectasis, 80 

congenital, 20 
Athetosis, 204 
Atmosphere, moist, maintaining of, 

52 . 
Atomizers, 50 

Atresia of anus, 22, 142 

Atrophic rhinitis, 63 

495 



496 



INDEX 



Atrophy, infantile, 354 

muscular, 227 
Auscultation of heart, 174 
Autumnal fever, 283 



Babies, blue, 24, 173 

Babinski's reflex, 205 

Bacterines, 453 

Balanitis, 247 

Baner's formula for cream mixtures, 

384 
Barley gruel, 369 

jelly, 370 

maltine, and milk mixture, 371 

water, 365 
Barlow's disease, 351 
Bath, alkaline, 440 

bran, 440 

compound glycerin, 441 
sulphur, 441 

for skin diseases, 440 

graduated cold, 429 

hot, 435 

hot-air, 438 
sitting, 439 

hygienic, 442 

linseed, 441 

mustard, 442 

prevention of chills after, 51 

salt, 439 

shower, 442 

sitz, 439 

sponge, 428, 442 

starch, 441 

tar, 442 

tepid, 442 

vapor, 436 

vinegar and mercury, 442 
Bathing in childhood, 40 

in infancy, 40 

of newborn, 38 
Bed, Children's Hospital, 39 

Klondike, 309, 310 

linen, soiled, care of, 312 

metabolic, 473 
Bed-sores, 293 
Beef juice, 371 

and milk, 371 
Bell's palsy, 229 
Bichlorid baths, 470 
Birth-marks, 260 



Birth palsy, 25, 214 
Bites, treatment of, 422 
Bladder, diseases of, 245 

exstrophy of, 246 
Blebs, 258 

Bleeders' disease, 194 
Blindness, adult, 25 
Blister, cantharides, 430 

fever, 115 
Blood, diseases of, 190 

specific gravity of, 191 
Blood-pressure, determination of, 

192 
Blood-vessels, diseases of, 190 
Blue babies, 24, 173 
Bones, tuberculosis of, 302 
Borborygmi, 147 
Bottles, feeding, 399 

sterilization of, 50 
Bottom milk, 382 
Bowing of tibia, 28 
Bow-legs, 28 

Bradford frame, Fauntleroy's modi- 
fication of, 466 
for fractures, 466 
Bradycardia, 175 
Brain, 197 

abscess of, 215 

diseases of, 211 

hemorrhage of, 25 

malformations of, 206 
Bran baths, 440 

Brat's apparatus for artificial res- 
piration, 456 
Breasts of newborn, 39 
Breath in digestive diseases, 113 
Breathing, stridulous, 66 
Bright's disease, 238 
Brill's disease, 279 

symptoms, 280 
Bronchiectasis, 76 
Bronchitis, 23, 70 

acute, 70 

capillary, 24 

chronic, 75 
Bronchopneumonia, 24, 94 

acute, 97 

tuberculous, 299 
Bubble quick, 401 
Buck's extension, application of, 

460 
Bulimia, 114 



INDEX 



497 



Bums, dressing of, 471 
emergency treatment, 422 

Buttermilk, 375 

care of, in house, 398 
conserve, 373 



Calculus, renal, 242 

vesical, 246 
Caloric method of infant feeding, 

391 

values, table of, 392-395 
Calorie, 391 
Camphorated oil, 431 
Cantharides blister, 430 
Capillary bronchitis, 24 
Carbohydrates, 358 
Care of milk in house, 397 
Catalepsy, 205 
Catarrhal laryngitis, 64 

stomatitis, 116 
Catheterization, 471 
Cautery, Paquelin, 472 
Cephalhematoma, 21 
Cephalodynia, 349 
Cerebral hemorrhages in newborn, 
22 

localization, 212 

meningitis, 207 

paralysis, 214 

pnemnonia, 106 
Cerebrospinal fever, 267 

meningitis, 207, 267 
Chapin dipper, 383 
Characteristic cry, 30 
Charcoal poultice, 432 
Chest, aspiration of, 472 
Cheyne-Stokes respiration, 59 
Chicken-pox, 337 
Child, crowing, 68 
Childhood, general hygiene of, 41 

nursing in, 36 

period of, 11 
Children's Hospital bed, 39 
ChUls, emergency treatment, 422 

prevention of, after baths, 51 
Chlorosis, 194 
Cholecystitis, 166 
Cholera infantum, 153 

morbus, 155 
Choluria, 234 
Chondrodystrophy, 216 
32 



Chorea, 25, 220 

heart murmur in, 24 
Choreiform movement, 204 
Chyluria, 234 
Circulation, 171 

fetal, 172 
Circulatory system, anatomy of, 
169 
diseases of, 24 
Cirrhosis of liver, 167 
Cleanliness in tuberculosis, 310 
Cleft palate, 115 
Clothing for outdoor sleeping, 310 

in childhood, 41 

in infancy, 41 

of newborn, 38 
Clubbed fingers in heart disease, 
177 

hands, 28 

toes in heart disease, 177 
Club-feet, 28 
Coffee-ground vomit, 132 
Cold bath, graduated, 429 

compress to rectum, 50 

in the head, 60 

pack, 429 
Colic, intestinal, 142 

renal, 242 
Collapse, treatment of, 422 
Colon, irrigation of, 415, 450 
Colostrum, 360 
Coma, 205 
Compensation, cardiac, 184 

period of, 184 
Complement fixation test, 46, 277 
Compresses, 434 

cold, to rectum, 50 
Condensed milk, 374 

care of, in house, 398 
Congestion of liver, 166 

of lungs, 93 
Conjunctivitis, 25, 255 
Constipation, 140 
Constitutional diseases, 26 
Contagious diseases, 26, 314 
acute, heart murmur in, 25 
definition of, 267 
nurse in, 51 
Continuous saline injection, 451 
Contra-indications for various 

drugs, 412 
Convulsions, 25, 203, 213 



498 



INDEX 



Convulsions, emergency treatment, 

423 
Cord, care of, 38 
Corrosion of esophagus, 129 
Coryza, 60 
Cough, 54 

Counter-irritation, 430 
Cowpox,_338 
Cows' milk, 362 
Coxalgia, 304 

extensions for, 460 
Coxitis, 304 
Cradles, improvised, 52 
Cranial nerves, 202 
Cream, 362 

dipping for, 387 

in artificial feeding, 385 

method for changing percentage 
. of, 388 

siphoning for, 386 
Cretinism, 215 

fetal, 216 
Crossed paralysis, 213 
Croup, emergency treatment, 422 

kettle, 447 

spasmodic, 65 

tent, 446 
Croupous exudate, 103 

pneumonia, 24, 94, loi 
Crowling's rule for dosage, 41 1 
Crusts, 258 
Cry, characteristic, 30 
Cliffs, 447 
Cups, dry, 431 

wet, 432 _ 
Cyclic vomiting, 132 



Dactylitis, tubercular, 307 
Deaf -mutism, 216 
Death, cause of, 31 
Defervescence, 264 
Deformities, 27 
Dextrimaltose, 380 
Diabetes insipidus, 236 

mellitus, 27, 350 
Diaphragmatic pleurisy, 89 
Diarrhea, 132, 133 

in tjrphoid fever, 289 

summer, 145 
Diastole, 182 
Dicrotic pulse, 175 



Diet in pylorospasm, 133 
Digestion, 29 

Digestive tract, diseases of, 112 
Digitalis poultice, 432 
Dilatation of heart, 188 

of stomach, 138 
Diphtheria, 324 
Dipper, Chapin, 383 
Dipping for cream, 383 
Diseases, inheritance in, 18 

peculiar to children, 18 
Disinfection, 470 

in scarlet fever, 317 

of excreta, 312, 470 

of hands, 470 

of stools in t3^hoid fever, 294 
Dislocation, congenital, of hip, 
28 

emergency treatment, 423 
Dosage, rule for reduction of, 476 

rules for, 411 
Douching, vaginal, 453 
Draughts, avoidance of, 49 
Dropsy in heart disease, 176 
Drowning, emergency treatment, 

423 
Drugs, characteristic pulses of, 
414 
dominant action of, 413 
poorly borne by children, 410 
used in children's diseases, with 

dose, 416 
well borne by children, 410 
which cause eruptions, 414 
color stools, 415 

urine, 415 
contract pupil, 414 
dilate pupil, 414 
quicken pulse, 413 
raise blood-pressure, 414 
slow pulse, 414 
Dry cups, 421 
Ductus arteriosus, 173 
Dura mater, 201 
Dysentery, 151 
Dyspepsia, atonic, 136 
catarrhal, 136 
chronic, 135 
nervous, 135 
Dysphagia, 114 
Dyspnea, 56 
emergency treatment, 424 



INDEX 



499 



Ear, diseases of, 25, 250 
nursing in, 256 

examination of, 51 

foreign bodies in, 424 

running, 25 

syringing, 443 
Earache, 255 

emergency treatment, 424 
Eczema, 26, 258 
Edema of glottis, 70 

pulmonary, 80 
Ehrlich's salvarsan, 278 
Eiweissmilch, 374 
Electricity, 469 
Embolism, 186 

Emergencies, treatment of, 422 
Emphysema, pulmonary, 80 
Empyema, 84 
Encephalocele, 206 
Endocarditis, 179 

after rheumatism, 25 

complicating rheumatism, 27 

fetal, 173 

ulcerative, 185 
Endocardiimi, 170 
Enemata, 452 
Enterocolitis, 151 

membranous, 152 
Enuresis, 25, 245 
Epilepsy, 218 

Jacksonian, 212 
Epileptiform convulsions, 203 
Epiphysitis, 307 
Epispadias, 246 
Epistaxis, 63 

treatment, 424 
Erb's paralysis, 22, 214 
Erysipelas, 20, 340 
Erythema, 258 
Esophagus, corrosion of, 129 

diseases of, 129 

stricture of, 1 29 
Eustace Smith's sign, 302 
Examination, method of holding 

child for, 49 
Examinations, general, 43 
Excreta, disinfection of, 312, 470 
Exercise, 408 

in childhood, 41 

in infancy, 41 
Expectoration, 56 
Exstrophy of bladder, 246 



Extension, Buck's, 461 
Extensions for fractures, 460 
Extremities, growth of, 14 
Eye, care of, 251 
compresses for, 434 
diseases of, 25, 249 
foreign bodies in, 252 
malformations of, 251 
syringing, 442 
Eyelid, everting, 252 



Fainting, treatment, 424 

Farina gruel, 369 

Fastigium, 264 

Fat percentages in mixtures, rules 

for, 396 
Fats, 357 

in artificial feeding, 378 
Fatty degeneration of heart, 188 

of newborn, 20 
Fauntleroy's modification of Brad- 
ford's frame, 466 
Febricula, 265 
Feces, 140 

incontinence of, 164 

milk, 140 
Feeding, adjuncts to, 408 

artificial, 376 

by stomach-tube, 450 
.during first year, 402 

schedule for, 401 
second year, 404 

infant, 356 

regurgitation after, 51 

rules for, 400 
Feet, care of, 51 
Fehling's solution, 236 
Female genitals, diseases of, 247 
Fetal circulation, 172 

cretinism, 216 

rickets, 216 
Fever, cerebrospinal, 267 

characteristics of, 264 

continued, 264 

hay-, 78 

hectic, 264 

inanition, 30 

infectious, 264 

intermittent, 264 

malarial, 270 

remittent, 264 



5CX) 



INDEX 



Fever, scarlet, 314 

types of, 264 

typhoid, 282 
Fibrinous bronchitis, 75 
Fibroid heart, 187 
Finger-sucking, 222 
Fingers, six, 28 

webbed, 28 
Finkelstein's eiweissmilch, 374 

food intoxication, 155 
Fissure of anus, 164 
Fixation, complement, 277 
Flaxseed poultice, 433 
Flexner's serum, 269 
Flint's murmur, 175 
Floating kidney, 243 
Flour gruel, 369 
Fontanels, anterior, closing of, 14 

posterior, closing of, 14 
Food, constituents of, 356 

intoxication, 155 
Foot-baths, hot, 414 

mustard, 440 
Foramen ovale, 172 

patulous, 173 
Fracture of femur, dressing for, 

461 
Fracture-box, 464 
Fractures, emergency treatment, 

425. 
extensions for, 460 
Frames, 466 
Frenum, ulcer of, 115 
Friction sound, 175 
Friedreich's ataxia, 227 
Fumigation, 470 
Furuncle of auditory canal, 255 
Furunculosis, 259 



Gait, scissors, 224 
Gall-stones, 165 
Gangrene of lung, 107 
Gastralgia, 137 
Gastric ulcer, 137 
Gastritis, 135 

chronic, 135 
Gastro-enteritis, 20 
Gastro-enterostomy for pyloro- 

spasm, 134 
Gastro-intestinal disorders, 24 
Gavage, 450 



Gelatin, preparation of, for infan- 
tile diarrhea, 371 

Genital tract, malformation of, 246 

Genitals, diseases of, 246 
of newborn, care of, 39 

Genito-urinary system, diseases of, 

malformations of, 25 
Genu valgum, 28 

varum, 28 
German gruel, 369 
Gingivitis, 115 
Girdle pain, 224 
Glandular system, diseases of, 25, 

261 
Glomeruli of kidneys, 231 
Glossary, 485 
Glossitis, 115 
Glottis, edema of, 70 
Glycerin bath, compound, 441 
Glycosuria, 234 
Gonorrhea, 247 

complement fixation test for, 46 
Grand mal, 218 
Gray tubercle, 300 
Griffith's weight chart, 12 
Growing pains, 27 
Growth during first year, 14 

of extremities, 14 
Gruel, apple, 368 

arrow-root, 370 

barley, 369 

farina, 369 

flour, 369 

German, 369 

oatmeal, 370 

rice flour, 372 
Gums, inflammation of, 115 



Habit, cry of, 30 

spasm, 222 

vomiting, 132 
Habits, injurious, 222 
Hamilton squint, 461 
Hands, clubbed, 28 

covers for, 467 

disinfection of, 470 
Hare-lip, 115 
Harrison's groove, 354 
Hay-fever, 78 
Head, circumference of, 14 



INDEX 



501 



Head-banging, 222 
Hearing, development of, 14 
Heart, action of, 173 

anatomy of, 169 

congenital malformations of, 24 

dilatation of, 188 

diseases of, 24 

clubbed fingers in, 177 

toes in, 177 
nursing in, 188 

failure, 454 

emergency treatment, 425 

fatty degeneration of, 188 

fibroid, 187 

hypertrophy of, 187 

malformations of, 173 

murmur in chorea, rheumatism, 
and acute contagious diseases, 
24 

sounds of, 174 

transposition of, 173 
Height, 14 

at birth, 14 
Heller's test, 235 
Hematemesis, 132 

treatment, 426 
Hematozoa, 271 
Hematuria, 234 
Hemiplegia, 203 
Hemocytometer, 191 
Hemoglobin, 191 
Hemoglobinometer, 191 
Hemoglobinuria, 234 

epidemic, 20 
Hemopericardium, 179 
Hemophilia, 194 
Hemoptysis, 79 

treatment, 426 
Hemorrhage from bowel, treatment, 
426 

from mouth, treatment, 426 

from nose, treatment, 424 

in newborn, 21 

of brain, 25 
Hemorrhoids, 164 
Hepatitis, 20 
Hepatization, gray, 103 

red, 102 
Hereditary syphilis, 26, 275 

cry of, 30 
Hernia, umbilical, in newborn, 22 
Herpes, 115 



Heubner's mustard bath, 430 

Hiccough, 132 

Hip, congenital dislocation of, 28 

Hives, 260 

Hodgkin's disease, 166, 263 

Holding-breath spells, 69 

treatment, 70 
Hook-worm, 163 
Hordeolum, 250 
Horseshoe kidney, 232 
Hospital bed, Children's, 39 
Hot apphcation, 434 

bath, 435 

foot-baths, 434 

pack, 435 
modified, 436 
Hot-air bath, 438 

sitting, 439 
Hot- water bags, 434 

care of, 50 
Human milk, 359 
Hunger, cry of, 30 
Hutchinson's teeth, 16, 276 
Hydrocele, 247 
Hydrocephalic cry, 209 
Hydrocephalus, 207, 215 

cry of, 30 
Hydro-encephalocele, 206 
Hydronephrosis, 243 
Hydropericardium, 179 
Hydrophobia, 279 
Hydrothorax, 89 
Hygienic management of children 

in general, 37 
H)^eremia, renal, 236 
Hyperesthesia, 205 

in hysteria, 219 
Hypermetropia, 250 
Hyperpyrexia, 264 
Hypertrophic rhinitis, 63 
Hypertrophy of heart, 187 
Hypodermics, 453 
Hypodermoclysis, 459 
Hypospadias, 246 
Hypostatic pneumonia, 107 
Hysteria, 218 

etiology, 219 

nursing in, 220 

symptoms, 219 
joint, 219 
motor, 219 
psychic, 219 



502 



INDEX 



Hysteria, symptoms, sensory, 219 

treatment, 220 
Hysteroidal convulsions, 203 



Ice-cap, 428 

Ichthyosis, congenital, 260 
Icterus neonatorum, 20, 165 
Ileocolitis, 151 
Impacted cerumen, 255 
Impetigo contagiosa, 260 
Impure milk, 146 
Inanition fever, 23, 29 
Incontinence of feces, 164 
Incubation, period of, 265 
Incubators, 42 
Indicanuria, 234 
Indigestion, acute gastric, 134 

cry of, 30 

intestinal, 143 
Infancy, general hygiene of, 40 

period of, 11 
Infant feeding, 356 

caloric method, 391 

foods, proprietary, 375 
recipes for, 365 
Infantile atrophy, 354 

paralysis, 224 
Infectious disease, definition, 267 
nurse in, 51 

fevers, 264 
acute, 26 
nursing in, 280 
Inflammation of liver, 20 
Inflammatory rheumatism, 347 
Influenza, 345 
Inhalations, technic of, 446 
Inheritance in diseases, 19 
Injections, intravenous, 459 

vaginal, 453 
Injurious habits, 222 
Insufficiency, aortic, 183 

mitral, 183 

pulmonary, 184 

tricuspid, 183 
Intermittent fever, quartan, 271 
quotidian, 271 

malarial fever, 272 
Intestinal colic, 142 

indigestion, 143 

obstruction, 159 
in newborn, 22 



Intestinal perforation in typhoid 

fever, 284, 285 
Intestines, diseases of, 140 

malformations of, 142 

obstruction of, 159 

tuberculosis of, 156 
Intoxication, food, 155 
Intravenous injections, 459 
Intubation, 332 
Intussusception, 159 
Invasion stage of fever, 264 
Iritis, 250 

Irrigation of colon, 450 
cold, 429 

rectal, 50 
Ischiorectal abscess, 164 
Itch, 260 



Jacksonian epilepsy, 212 
Jaundice, 20, 165 

catarrhal, 165 
Joints, tuberculosis of, 302 
Junket, 374 



Keratitis, 350, 352 
Kernig's sign, 210 
Kidney, amyloid, 242 

anatomy of, 231 

after scarlet fever, 25 

diseases of, nursing in, 244 

floating, 243 

horseshoe, 232 

malformations of, 232 

sarcoma of, 244 

tuberculosis of, 243 
Klondike bed, 309, 310 
Knee-jerks, 204 
Knock-knee, 28 
Koplik's sign, 322 
Kumiss and bean flour, 374 
Kyphosis, 304, 354 



Lacunar angina, 1 20 
La grippe, 345 
Laminated teeth, 17 
Landry's paralysis, 227 
Laryngismus stridulus, 25, 68, 70 

emergency treatment, 426 
Laryngitis, 64 



INDEX 



503 



Laryngitis, acute catarrhal, 64 

S3^hilitic, 65 

tubercular, 65 
Lavage of stomach, 448 
in pylorospasm, 134 
Leukemia, 194 
Leukocytosis, 194 
Lice, 260 
Linseed bath, 441 
Lisping, 222 
Lithuria, 233 
Liver, cirrhosis of, 166 

congestion of, 166 

diseases of, 165 

inflammation of , 20 
Lobar pneumonia, 94, loi 
Lockjaw, 278 
Lumbago, 349 
Lumbar puncture, 210 
Lung, abscess of, 107 

anatomy of, 91 

diseases of, 91 

congestion of, 93 

gangrene of, 107 

immobilization in tuberculosis, 

307 
Lungmotor, 456 
Lupus vulgaris, 260 
Lymph-glands, bronchial, tubercu- 
losis of, 302 
L5niiphatism, 262 
Lysis, 264 



Macules, 257 

Malaria, 270 

Malarial fever, 26, 270 

Male genitals, diseases of, 247 

Malt soup mixture, 372 

Maltose, 380 

Marasmus, 27, 354 

cry of, 30 
Masks for skin diseases, 468 
Massage, 469 
Mastitis in newborn, 22 
Mastoid disease, 25 
Mastoiditis, 255 
Masturbation, 222 
Measles, 320 
Meconium, 140 
Medical terminology, 484 
Meninges, diseases of, 207 



Meninges of brain, 201 
Meningitis, 20, 207 

cerebral, 207 

cerebrospinal, 207, 267 

cry of, 30 

tubercular, 25, 208 
Meningocele, 206 
Mercurial stomatitis, 118 
Metabolic bed, 473 
Metric system, 475 
Microcephalus, 206 
Micromelia, 216 
Miliaria, 258 
Miliary tuberculosis, 301 
Milk, bottom, 382 

care of, in house, 397 

condensed, 374 

care of, in house, 398 

cows', 362 

digestion of, 130 

examination of, 361 

feces, 140 

impure, 146 

infection, 146 

methods of modifying, 384 

pasteurized, 363 

peptonized, 367 

protein, 374 

rice, 365 

siphoning, 382 

skimmed, 381 

sterilized, 364 

teeth, average age of eruption of, 

15 
woman's, 359 

Mineral salts in food, 359 

Minim, method of obtaining frac- 
tional part, 477 

Mitral insufficiency, 183 
stenosis, 182 

Mixtures, top-milk, 386 

Modifying milk, methods of, 384 

Moist atmosphere, maintaining, 

Monoplegia, 203 
Mouth, diseases of, 115 

inflammation of, 116 

malformation of, 114 

of newborn, care of, 38 

syringing of, 446 
Mumps, 344 
Murmur, cardiac, 174 



504 



INDEX 



Murmur, heart, in chorea, rheu- 
matism, and acute contagious 
diseases, 24 

Murmurs in endocarditis, 181 

Muscular rheumatism, 348 

Mustard bath, 440 
Huebner's, 430 
foot-bath, 440 
pack, 431 
paste, 430 
plaster, 430 
poultice, 430 

Myelitis, 223 

Myocarditis, 187 

Myopia, 250 



Nail-biting, 222 
Nasal syringing, 444 
Nebulizers, 50 
Nephritis, 238 

chronic interstitial, 240 
parenchymatous, 239 
Nerves, cranial, 202 

diseases of, 228 

spinal, 202 

sympathetic, 202 
Nervous system, anatomy of, 197 
diseases of, 25 

peculiar in children, 205 
nursing in, 229 
Nervousness, treatment of, 426 
Neuritis, 228 

multiple, 228 
Nevus, 260 

Newborn, ^acute pyogenic diseases 
of, 20 

asphyxia of, 19, 458 

bathing of , 38 

care of, 37 

cerebral hemorrhages in, 22 

clothing of, 38 

diseases of, 19 
prophylaxis in, 21 

facial paralysis in, 22 

fatty degeneration of, 20 

hemorrhages in, 21 

intestinal obstruction in, 22 

mastitis in, 22 

period of, 11 

umbilical hernia in, 22 
Night terrors, 223 



Nipples, 399 

babies', care of, 51 
Nodding spasm, 25, 222 
Noma, 117 

Normal salt solution, 420 
Nose, foreign bodies in, 425 
Nosebleed, treatment, 424 
Nursery, general hygiene of, 41 
Nursing in childhood, 36 
Nutrient enemata, 452 
Nutrition, 356 
Nutritional diseases, 26, 351 
Nystagmus, 222, 253 



Oatmeal gruel, 368 

jelly, 371 

water, 365 
Obstetric hand, 221 
Obstruction, intestinal, 158 

chronic, 160 
Oiled silk jacket, 466 
Onychia, 260 

Operation, preparation for, 471 
Ophthalmia, 25 

neonatorum, 20, 251 
Opisthotonos, 209 
Orthopedics, 27 
Orthopnea, 57 
Osteomyelitis, 20 

tubercular, 306 
Otitis media, 25, 255 
Outdoor sleeping, clothing for, 310 

treatment of tuberculosis, 309 
Oxyuris vermicularis, 163 



Pack, hot, 435 
Pain, cry of, 30 
Palpitation of heart, 176 
Palsy, Bell's, 229 
Pap, 369 
Papules, 257 
Paquelin cautery, 472 
Paralysis, 25 

birth, 25 

cerebral, 214 

crossed, 213 

definition of, 203 

Erb's, 22, 214 

facial, 22 



INDEX 



505 



Paralysis, infantile, 224 

Landry's, 227 

post-diphtheritic, 229, 326 
Paraplegia, 203 
Parasites, animal, 161 
Paresthesia, 205 
Parotitis, 344 
Pasteurized milk, 363 
Peculiarities of children's diseases, 

II 
Pediculosis capitis, 260 

pubis, 260 
Pemphigus neonatorum, 20 
Pennsylvania quarantine laws, 32- 

35 
Peptonized milk, 367 
Peptonizing mixture, 368 
Percentage of cream, method for 
changing, 383 

of mixtures, methods of deter- 
mining, 396 
Percussion of heart, 1 74 
Perforation, emergency treatment, 
426 

in typhoid fever, 284, 289 
Pericarditis, 20, 176 
Pericardium, 171 
Peritonitis, 20, 167 
Pernicious anemia, 194 
Pertussis, 341 
Petit mal, 218 
Peyer's patches, 284 
Phagocytosis, 453 
Pharyngitis, 124 

atrophic, 126 

chronic, 126 

hypertrophic, 126 

phlegmonous, 126 
Phimosis, 25, 246 
Photophobia, 248 
Pia, 202 
Pica, 114 
Pigeon breast, 23 
Piles, 164 
Pink-eye, 252 
Pitted teeth, 17 
Pitting in small-pox, preventing of, 

337 
Plaster casts, 465 
Plethora, 194 
Pleurisy, 81 

hemorrhagic, 89 



Pleurodynia, 89, 349 
Pleuropneumonia, 106 
Pneumohydro thorax, 90 
Pneumonia, 20, 94 

aspiration, 107 

cerebral, 106 

croupous, 24 

cry of, 30 

embolic septic, 108 

hypostatic, 107 

lobar, loi 

serum treatment, 108 

treatment of, 108 

typhoid, 291 
Pneumonic consolidation, 103 
Pneumopericardium, 179 
Pneumothorax, 90 

artificial, in tuberculosis, 307 
Poisons and their antidotes, 420 
Poliomyelitis, acute anterior, 224 
Polydactyly, 28 
Polyuria, 233, _ 234 
Post-diphtheric paralysis, 229, 326 
Pott's disease, 302 
Poultices, 432 
Premature babies, 42 
Pressure sjonptoms, 211 
Prognosis in diseases of children, 31 
Proctitis, 164 
Prolapse of rectimi, 164 

emergency treatment, 427 
Promises to child, 52 
Prone-pressure method of artificial 

respiration, 457 
Proteids, 357 

in artificial feeding, 379 
Protein milk, 374 
Pseudocrisis in pneumonia, 105 
Pseudodiphtheria, 123 
Pseudohypertrophy of muscles, 227 
Psoas abscess, 304 
Pulmonary insufficiency, 184 

edema, 80 

emphysema, 78 

stenosis, 184 
Pulmotor, 456 
Pulse, 29, 175 

dicrotic, 175 

taking of, 45 

venous, 175 

water-hammer, 176 
Purpura, 195 



5o6 



INDEX 



Purpura hemorrhagica, 195 
Pustules, 258 
Pyelitis, 243 
Pylorospasm, 132 

diet in, 133 

gastro-enterostomy for, 134 

lavage in, 134 

operation in, 134 

symptoms, 133 

treatment, 133 

weight-chart in, 134 



Quarantine, regulations of, 32 
Quinsy, 120 



Rabies, 279 

Rachitic rosary, 353 

Rachitis, 352 

Ranula, 114 

Rashes, dates when they appear, 

266 
Reaction, Wassermann, 46 
Rectal irrigation, 50 
Rectum, cold compresses to, 50 

diseases of, 164 

inflammation of, 164 

prolapse of, 164 

emergency treatment, 427 
Reduplication of heart sounds, 184 
Regurgitation, 182 

after feeding, 51 

aortic, 183 

mitral, 183 
Remittent malarial fever, 273 
Renal calculus, 242 

hyperemia, 236 
Resolution, stage of, 103 
Respiration, 29, 57 

artificial, 454 
Respiratory failure, 455 

emergency treatment, 427 

tract, diseases of, 23, 54 
Rest, 408 

Resuscitation, methods of, 454 
Retropharyngeal abscess, 126 
Rhagades, 275 
Rheumatism, 26, 347 

acute articular, 347 

endocarditis after, 25 
complicating, 27 



Rheumatism, heart murmur in, 24 

inflammatory, 347 

muscular, 348 
Rhinitis, 60 

acute, 60 

atrophic, 63 

chronic, 61 

hypertrophic, 63 
Rice and oatmeal water, 365 

flour gruel, 3 70 

milk, 365 
Rickets, 27, 49, 352 

fetal, 216 
Rickety children, eruption of teeth 

in, 15 
Rogers' sphygmomanometer, 192 
Rose cold, 78 
Rotheln, 323 
Round worms, 162 
Rubella, 323 
Rubeola, 320 
Running ears, 25 
Rusty sputum, 56 



Salt bath, 439 

solution, normal, 410 

continuous injection, 451 

Salvarsan, 278 

Salvator, 456 

Sarcoma of kidney, 244 

Sardonic grin, 278 

Scabies, 260 

Scales, 258 

Scarlatina, 314 
miharis, 316 

Scarlet fever, 314 
anginoid, 316 
kidneys after, 26 
malignant, 317 

Schafer method of artificial respira- 
tion, 457 

Sciatica, 228 

Scissors gait, 224 

Sclerema, 23 

Sclerosis, 224 

Scoliosis, 354 

Scorbutus, 351 

Screw-driver teeth, 17 

Scurvy, 27, 351 

Seat- worms, 163 

Seborrhea, 258 



INDEX 



507 



Serum, Flexner's, 269 

treatment of pneumonia, 108 
Shock, emergency treatment, 427 
Shower bath, 441 
Sight, development of, 14 
Silvester's method of artificial res- 
piration, 456 
Singultus, 132 
Siphoning milk, apparatus for, 382 

method for, 382 
Sitting hot-air bath, 439 
Sitz bath, 439 
Six fingers, 24 
Skiagraphy, 469 
Skimmed milk, 381 
Skin, diseases of, 25, 257 

masks for, 468 
Sleep, disorders of, 223 

in childhood, 41 

in infancy, 41 

in newborn babe, 40 
Small-pox, 334 

black, 336 

malignant, 336 
Smell, development of, 14 
Solutions, percentage, rules for, 477 
Spasmodic croup, 65 
Spasms, nodding, 25 
Spasmus gyrans, 222 
Speech, disorders of, 222 
Sphygmomanometer, 192 
Spice poultice, 433 
Spinal cord, anatomy of, 200 
diseases of, 223 

nerves, 202 
Spine, observation of, 49 
Spirochaeta pallida, 277 
Spitting of blood, treatment, 426 
Spleen, diseases of, 166 

removal of, 167 
Splint, Hamilton, 461 
Splints, 463 
Sponge bath, 428, 442 
Spotted fever, 267 
Sputum, 56 

collecting, for examination, 313 

disposal of, 312 

in tuberculosis, 313 
Starch bath, 441 

poultice, .433 
Stenosis, aortic, 183 

mitral, 182 



Stenosis of lacrimal duct, 250 

pulmonary, 184 

tricuspid, 183 
Sterilization of bottles, 50 

of thermometer, 52 
Sterilized milk, 364 
Stomach, capacity of, 129 

dilatation of, 138 

diseases of, 129 
nursing in, 139 

inflammation of, 135 

malformations of, 134 

washing, 448 
Stomach-tube, feeding by, 450 
Stomatitits, 116 

aphthous, 116 

gangrenous, 117 

parasitic, 117 

mercurial, 118 

ulcerative, 117 
Stools, disinfection of, in typhoid 

fever, 294 
Strabismus, 25, 250 
Strait jacket, 467 
Strangulation of intestine, 160 
Strawberry tongue, 112, 315 
Stricture of esophagus, 1 29 
Stridor, congenital, 22 
Stridulous breathing, 66 
Strumous children, eruption of 

teeth in, 15 
Stuttering, 222 
St. Vitus' dance, 25, 220 
Stye, 250 

Subsultus tendinum, 100 
Sugar in urine, 236 
Sulphur bath, 441 
Summer diarrhea, 145 
Sunstroke, treatment, 427 
Sympathetic nerves, 202 
Symptomatology of children's dis- 
eases, 28 
Syncope, 205 
Synechia, 250 
Syphilis, 275 

hereditary, 26 
cry of, 30 

Wassermann reaction in, 46 
Syphilitic laryngitis, 65 
Syringing, 442 

ear, 443 

eye, 442 



5o8 



INDEX 



Syringing, mouth, 446 

nose, 444 
Syringomyelia, 227 
Systole, 182 
Systolic sound, 174 

Tache cerebrale, 269 
Tachycardia, 175 
Taenia saginata, 161 

solium, 161 
Talipes valgus, 28 

varus, 28 
Talking, 15 
Tape- worms, 161 
Tar bath, 442 
Teeth, 15 

eruption of, 15 

in strumous or rickety children, 

15 
Hutchinson's, 16 
laminated, 17 
milk, average age of eruption of, 

15 

permanent, average age of erup- 
tion of, 15 

pitted, 17 

screw-driver, 17 
Temper, cry of, 30 
Temperature, 28 

changing Centigrade to Fahren- 
heit, 478 

methods of reduction, 428 

sudden rise of, 51 

taking, of, 43, 44, 50 
Tenesmus, 142 
Tepid bath, 442 
Testicle, undescended, 246 
Test-meals, 139 
Tetanic convulsions, 203 
Tetanus, 20, 278 
Tetany, 25, 221 
Therapeutic limit, 411 
Therapeutics, 410 
Thermometer, sterilization of, 52 
Throat, examination of, 51 

foreign bodies in, 425 
Thrombosis, 215 
Thrush, 117 
Tibia, bowing of, 28 
Tinea circinata, 260 

tonsurans, 260 
Tongue in digestive diseases, 112 



Tongue, inflammation of, 115 

strawberry, 112 
Tongue-tie, 115 
Tonsillectomy, 122 
Tonsillitis, 119 
Tonsils, hypertrophy of, 120 
Top-milk mixtures, 386 
Tormina, 142 
Torticollis, 222, 349 
Touch, development of, 14 
Tracheotomy, 333 
Tremors, 204 
Tricuspid stenosis, 183 
Trismus, 278 
Trousseau's sign, 221 
Tubercular adenitis, 26, 307 

arthritis, 306 

dactylitis, 307 

laryngitis, 65 

meningitis, 25, 208 

osteomyelitis, 306 
Tuberculosis, 26, 296 

acute miliary, 301 

care of soiled bed linen in, 312 

cleanliness in, 310 

disinfection of excreta in, 312 

lung immobilization in, 307 

nursing in, 308 

of bones, 302 

of bronchial lymph-glands, 302 

of intestines, 155 

of joints, 302 

of kidney, 243 

outdoor treatment, 309 

treatment of, 307 
Tuberculous bronchopneumonia, 

299 
Tumors, cerebral, 215 
Turpentine stupe, 431 
Tympanites in typhoid fever, 289 
Typhoid fever, 26, 282 

pneumonia, 291 

spine, 290 

state in bronchopneumonia, 100 

ulcer, 284 

vaccination against, 291 

walking, 282 
Typhus fever, 279 
symptoms, 280 

Ulcer, gastric, 137 
of frenum, 115 



INDEX 



509 



Ulcer, typhoid, 284 

Ulcerative stomatitis, 117 

Uncinaria duodenalis, 163 

Undescended testicle, 246 

Urea, 115 

Uremia, 237 

Urethritis, 247 

Urinary tract, diseases of, 231 

Urine, 233 

collecting of, 234 
examination of, 235 
method of collecting, 45 
retention of, treatment, 428 
suppression of, treatment, 427 

Urotropin, 227 

Urticaria, 260 

Uvulitis, 126 



Vaccination, 338 

against typhoid, 291 
Vaccines, 41 5 > 453 
Vaccinia, 338 
Vaginal douching, 453 

injections, 453 
Vaginitis, 247 
Vapor bath, 436 
Varicella, 337 
Variola, 334 
Varioloid, 336 
Ventilation,* 409 
Vesical calculus, 246 

spasm, 246 
Vesicles, 258 
Vincent's angina, 123 
Vinegar and mercury bath, 442 
Volvulus, 160 
Vomiting, 131 

cyclic, 132 

habit, 132 

of blood, treatment, 426 

persistent, treatment, 428 



Vomitus, disinfection of, in per- 
tussis, 52 
Von Jaksch's disease, 194 

Walking, 14 

typhoid, 286 
Wassermann reaction, 46, 277 
Water, drinking of, 48 

in food, 359 
Water-hammer pulse, 176 
Weakness, cry of, 30 
Weaning, 377 
Webbed fingers, 28 
Weight, II 

chart, 13 
Griffith's, 12 
in pylorospasm, 134 

table, 14 
Weights and measures, 474 
Wet cups, 432 
Whey, 366 

and milk, 366 

and white of egg, 366 

milk, and white of egg, 366 
Whooping-cough, 341 
Widal reaction, 290 
Wine measure, table of, 474 

whey, 367 
Woman's milk and cows' milk, 

difference between, 362 
Worms, intestinal, 161 

round, 162 

seat-, 163 

tape-, 161 
Wounds, dressing of, 471 

emergency treatment, 428 
Wry-neck, 222 

Yellow tubercle, 300 
Young's rule for dosage, 411 
Youth, general hygiene in, 41 
period of, 1 1 



Books for Nurses 



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Sanders' Nursing 



A NEW WORK 



Miss Sanders' new book is undoubtedly the most 
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Dunton's Occupation Therapy 

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Stoney's Materia Medica 

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Stoney's Surgical Technic new m) edition 

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Davis' Obstetric & Gynecologic Nursing 

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Eye, Ear, Nose, and Throat Nursing 

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American Pocket Dictionary new (9!!f)^ED^™N 

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Lewis' Anatomy and Physiology 

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Bohm & Painter's Massage 

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Octavo of gi pages, with g? illustrations. By Max Bohm, M. D., 
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tions are full-page line drawings. 

Mechanotherapy (Massage and Medical Gymnastics). By AXEL V. 
Grafstrom, B. Sc, M. D., Attending Physician Gustavus Adolphus 
Orphanage, Jamestown, New York. i6mo of 200 pages. 

Cloth, $1.25 net 

Friedenwald and Ruhrah's Dietetics for 

il UrSeS NEW (3d) EDITION 

This work has been prepared to meet the needs of the nurse, 
both in training school and after graduation. Ajnericaii Jotir- 
nal of Niirsiiig says it "is exactly the book for which nurses 
and others have long and vainly sought." 

Dietetics for Nurses. By Julius Friedenwald, M. D., Professor of 
Diseases of the Stomach, and John Ruhrah, M.D., Professor of 
Diseases of Children, College of Physicians and Surgeons, Baltimore. 
i2mo volume of 431 pages. Cloth, $1.50 net 



FOURTH 
EDITION 



Friedenwald & Ruhrah on Diet 

This work is a fuller treatment of the subject of diet, pre- 
sented along the same lines as the smaller work. Everything 
concerning diets, their preparation and use, coloric values, 
rectal feeding, etc., is here given in the light of the most re- 
cent researches. 

Diet in Health and Disease. By Julius Friedenwald, M.D., and 
John Ruhrah, M.D. Octavo volume of 857 pages. Cloth, $4.00 net 



Pyle's Personal Hygiene ^^EWiwTJmol 

Dr. Pyle's work discusses the care of the teeth, skin, com- 
plexion and hair, bathing, clothing, mouth breathing, catch- 
ing cold; singing, care of the eyes, school hygiene, body 
posture, ventilation, heating, water supply, house-cleaning, 
home gymnastics, first-aid measures, etc. 

A Manual of Personal Hygiene. Edited by Walter L. Pyle, M. D., 
Wilis Eye Hospital, Philadelphia. i2mo, 543 pages of illus. $1.50 net 

Galbraith's Personal Hygiene and Physical 
Training for Women illustrated 

Dr. Galbraith's book tells you how to train the physical pow- 
ers to their highest degree of efficiency by means of fresh air, 
tonic baths, proper food and clothing, gymnastic and outdoor 
exercise. There are chapters on the skin, hair, development 
of the form, carriage, dancing, walking, running, swimming, 
rowing, and other outdoor sports. 

Personal Hygiene and Physical Training for Women. By Anna M. 
Galbraith, M.D., Fellow New York Academyof Medicine. 12010 of 
371 pages, illustrated. Cloth, $2.00 net 

Galbraith's Four Epochs of Woman's Life 

This book covers each epoch fully, in a clean, instructive way, 
taking up puberty, menstruation, marriage, sexual instinct, 
sterility, pregnancy, confinement, nursing, the menopause. 

The Four Epochs of Woman's Life. By Anna M. Galbraith, M. D. 
With an Introductory Note by John H. Musser, M. D., University of 
Pennsylvania. i2ino of 247 pages. Cloth, $1.50 net 



JUST OUT 
NEW (6th) EDITION 



Griffith's Care of the Baby 

Here is a book that tells in simple, straightforward language 
exactly how to care for the baby in health and disease ; how 
to keep it well and strong; and should it fall sick, how to 
carry out the physician's instructions and nurse it back to 
health again. 

The Care of the Baby. By J. P. Crozer Griffith, M.D., Univers- 
ity of Pennsylvania. i2mo of 458 pages, illustrated. Cloth, $1.50 net 



Hoxie & Laptad's Medicine for Nurses 

Medicine for Nurses and Housemothers. By Gkorgk 
Howard Hoxie:, M. D., University of Kansas; and 
Peari, L. Laptad. 12mo of 351 pages, illustrated. 
Cloth, $1.50 net. New {2d) Edition. 

This book gives you information that will help you to carry out the 
directions of the physician and care for the sick in emergencies. It 
teaches you how to recognize any signs and changes that may occur be- 
tween visits of the physician, and, if necessary, to meet conditions until 
the physician's arrival. 

Boyd's State Registration for Nurses 

State Registration for Nurses. By Louiie Croft Boyd, 
R. N., Graduate Colorado Training School for Nurses. 
Octovo of 149 pages. Cloth, $1.25 net. Ne-iu {2d) Edition, 

Morrow's Immediate Care of Injured 

Immediate Care of the Injured. By Albert S. Mor- 
row, M. D., New York City Home for Aged and In- 
firm. Octavo of 354 pages, with 242 illustrations. 
Cloth, $2.50 net. Neiju {2d) Edition. 

deNancrede's Anatomy new (7th) edition 

Essentials of Anatomy. By Charlks B. G. deNan- 
crkde;, M. D., University of Michigan. 12mo of 400 
pages, 180 illustrations. Cloth, $1.00 net. 

Morris' Materia Medica new (7th) edition 

Essentials of Materia Medica, Therapeutics, and Pre- 
scription Writing. By Hknry Morris, M. D. Re- 
vised by W. A. Bastkdo, M. D., Columbia University, 
New York. 12mo of 300 pages, illustrated. 

Cloth, $1.00 net. 

Register's Fever Nursing 

A Text Book on Practical Fever Nursing. By Kdward 
C. REGISTER, M. D., North Carolina Medical College. 
Octavo of 350 pages, illustrated. Cloth, $2.50 net. 



